Form Fx-0002-0215 Additional Contributions Tax-Sheltered (Acts) Program Provider Election And Allocation (Page 2 of 2) in pdf

Form Fx-0002-0215 Additional Contributions Tax-Sheltered (Acts) Program Provider Election And Allocation Page 2

FX-0002-0215

ADDITIONAL CONTRIBUTIONS TAX-SHELTERED (ACTS) PROGRAM

CARRIER ELECTION AND ALLOCATION

GENERAL INFORMATION

Employees of county colleges, state universities and colleges, the Commission on Higher Education, the

Department of Education, and the Office of Student Assistance can participate in the Additional Contributions Tax-

Sheltered (ACTS) Program. ABP members have the option to select the same individual providers through the reg-

ular Alternate Benefit Program.

A Provider Election and Allocation Form must be filed to identify the investment carrier(s) with which you want your

contributions invested. If you are a new participant, this form must be accompanied by the Salary Reduction

Agreement form.

INSTRUCTIONS FOR APPLICANTS:

Please read all information carefully when completing this form. Where applicable, indicate your name, mailing

address, social security number, and telephone number where you may be reached during daytime working hours.

If you are a member of a state-administered retirement system, check the name of the system and provide your

membership number.

To authorize any investment provider(s), indicate in the relevant box if your request is an initial or a subsequent

request. A SUBSEQUENT REQUEST WILL REPLACE ALL PREVIOUS SELECTIONS. Place a mark in the box

to the left of the name of the provider(s) you have selected and provide your account number assigned with that

provider. Enter the percent of the reduction that you want allocated to any provider(s). Percentages must be in

whole numbers and totals must equal 100%.

Sign and date the form and have your certifying officer complete the employer information. A copy will be returned

to you after confirmation of receipt indicating the date your reduction will take effect.

It is your responsibility to complete the necessary forms to establish a valid account with the carrier(s) you select

for your investments. If you fail to establish an account with the provider(s), you may lose earnings from your con-

tributions. Additionally, the provider(s) will return your contributions to the Division of Pensions and Benefits and

your participation will be delayed.

INSTRUCTIONS FOR EMPLOYERS

Please enter the name, address and payroll number of your agency. The designated certifying officer must sign the

form indicating his/her title, telephone number, and the date. Upon completion, return this form to:

Division of Pensions and Benefits

ACTS Program

PO BOX 295

Trenton, NJ 08625-0295

Form Fx-0002-0215 Additional Contributions Tax-Sheltered (Acts) Program Provider Election And Allocation Page 2