Form Fx-0002-0215 Additional Contributions Tax-Sheltered (Acts) Program Provider Election And Allocation

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FX-0002-0215
STATE OF NEW JERSEY
DEPARTMENT OF THE TREASURY
DIVISION OF PENSIONS AND BENEFITS
ADDITIONAL CONTRIBUTIONS TAX-SHELTERED (ACTS) PROGRAM
PROVIDER ELECTION AND ALLOCATION
Name _________________________________________
_______________________________________
______________
LAST
FIRST
MIDDLE INITIAL
__________________________
Social Security No. __________________________________
Membership No.
(IF APPLICABLE)
o
o
o
Retirement System
PERS
TPAF
PFRS
(IF APPLICABLE)
Address ____________________________________________________________________________________________________
STREET OR RD#
APARTMENT NO.
___________________________________________________________________________________________________________
CITY
STATE
ZIP
Daytime Telephone No. (__________) ____________________________________________________________________________
AUTHORIZED INVESTMENT CARRIERS
Select any number of investment carriers and allocate the percentage of your contributions to each one, totaling 100%. Percentages
must be whole numbers. YOU MUST ESTABLISH A VALID ACCOUNT DIRECTLY WITH THE PROVIDER(S) YOU SELECT BEFORE
COMPLETING THIS FORM. Only two changes are allowed in any calendar year.
o
o
Check One:
Initial Election
Subsequent Election
Carrier Account No.
Percentage
o
AIG VALIC
________________________
_______________ %
o
AXA Financial (Equitable)
________________________
_______________ %
o
VOYA Financial Services
________________________
_______________ %
o
MassMutual Retirement Services
________________________
_______________ %
o
Met Life (formerly Travelers/CitiStreet)
________________________
_______________ %
o
Prudential
________________________
_______________ %
o
TIAA-CREF
________________________
_______________ %
100%
I elect to allocate my total employee tax sheltered contributions as indicated above. This allocation becomes effective within 45 days of
receipt of a properly completed form. I have read and understand the information on the back of this application.
Employee Signature ______________________________________________________________
Date ____________________
EMPLOYER SECTION
Name of Employing
Agency _____________________________________________________________________
Payroll No. __________________
Address of Employing
Agency _____________________________________________________________________________________________________
Certifying Officer
Signature _____________________________________________________
Title ______________________________________
Telephone No. _______________________________________________________________
Date ________________________
Mail completed form to: Division of Pensions and Benefits, ACTS Program, PO Box 295, Trenton, NJ 08625-0295
FOR DIVISION USE ONLY
SALARY REDUCTION AGREEMENT - CONFIRMATION OF RECEIPT BY DIVISION OF PENSIONS AND BENEFITS
Effective Authorized
Date ________________________
Signature _________________________________________
Date ______________

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