Form Fp-0867-0215 Alternate Benefit Program Enrollment/transfer Application (Page 3 of 3) in pdf

Form Fp-0867-0215 Alternate Benefit Program Enrollment/transfer Application Page 3

STATE OF NEW JERSEY

FP-0867-0215

PO Box 295

DIVISION OF PENSIONS AND BENEFITS

Trenton NJ 08625-0295

ALTERNATE BENEFIT PROGRAM

ELECTION OF RETIREMENT COVERAGE

TRANSFER FROM PERS/TPAF

Name ____________________________________________________________________________

Social Security # ________________________

Title _____________________________________

Employing Institution _________________________________________________________________

I certify that I am now a member of:

The NJ Teachers' Pension and Annuity Fund

and my membership number in the Fund is: # ___________________________

The NJ Public Employees' Retirement System

and my membership number is: # ____________________________________

— SIGN ONE STATEMENT ONLY —

I wish to transfer my pension contributions to the Alternate Benefit Program and waive my statutory right to

remain in or transfer to the Public Employees' Retirement System. I understand that my decision is irrevocable.

I wish my accumulated pension deductions and any contingent reserve funds to which I am entitled to be invest-

ed with the one investment carrier designated below:

_____ AXA Financial (Equitable)

_____ MassMutual Retirement Services (formerly The Hartford)

_____ VOYA Financial Services

_____ MetLife (formerly Travelers/CitiStreet)

_____ Prudential

_____ TIAA-CREF

_____ VALIC

______________________________________________

____________________________

EMPLOYEE SIGNATURE

DATE

— OR —

I wish to remain in the Public Employees' Retirement System (PERS) or transfer my pension contributions to

the PERS from the Teachers' Pension and Annuity Fund and waive my statutory right to

participate in the Alternate Benefit Program. I understand that my decision is irrevocable.

______________________________________________

____________________________

EMPLOYEE SIGNATURE

DATE

Form Fp-0867-0215 Alternate Benefit Program Enrollment/transfer Application Page 3