Application For Transfer / Rehire Form
ADVERTISEMENT
1PO Box 295
ABP-80-0069-0514
Trenton, NJ 08625-0295
STATE OF NEW JERSEY — DEPARTMENT OF THE TREASURY
DIVISION OF PENSIONS AND BENEFITS
Alternate Benefit Program
APPLICATION FOR TRANSFER / REHIRE
(INTRA-FUND)
This application must be completed by all Alternate Benefit Program participants
who are transferring employers and continuing their Alternate Benefit Program participation.
PART I: To be completed by the employee,
(Please Print)
Name:__________________________________________________________________________________
Address: ________________________________________________________________________________
I, _______________________________________, ABP Membership No.: ___________________________
(Assigned by Division of Pensions and Benefits)
resigned my position as _______________________________ at ___________________________________
on the _______ day of _________________________, 20 _____. I hereby notify the Division of Pensions and
Benefits that I have accepted employment at _______________________________________ and request that
the Division continue my participation in the Alternate Benefit Program with this new employer.
IMPORTANT: Any change you wish to make to beneficiaries or to payroll deductions must be
made on the appropriate change forms which may be obtained from your benefits officer. If
you had a Salary-Reduction Agreement with your former employer and wish to
continue the reduction, you must sign a new agreement with your new employer.
PART II: To be completed by the new employer.
1. Employee’s Title: _______________________________________________________________________
2. Appointment Date: ___________________________________
3. Full-Time Employee:
Yes
No
4. Employed:
Ten-Months
Twelve-Months
5. Academic:
Yes
No
6. Social Security No.: ________________________________________
7. Annual Base Salary: $ ______________________ 8. Location or Payroll No.: _____________________
I
certify that this employee and position meets the eligibility criteria for the retirement system as provided by law. I acknowl-
edge that I am subject to penalty for falsifying or permitting to be falsified any record, application, form, or report of the
retirement system in an attempt to defraud the system pursuant to N.J.S.A. 43:3C-15. (Two Signatures Required)
_______________________________________________
__________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Signature of Certifying Officer
Title
Date
_______________________________________________
__________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Signature of Certifying Officer’s Supervisor
Title
Date
_______________________________________________
_____________________________________
Institution
Date
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial