Form Fs-0086-0306p Supplemental Annuity Collective Trust
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1FS-0086-0306p
STATE OF NEW JERSEY — DEPARTMENT OF THE TREASURY
ENROLLMENT
DIVISION OF PENSIONS AND BENEFITS
P. O. BOX 295
REQUEST
TRENTON, NJ 08625-0295
SUPPLEMENTAL ANNUITY COLLECTIVE TRUST
PART 1 — TO BE COMPLETED BY PARTICIPANT (Please print or type)
1.
-
NAME
Last, First, Middle _______________________________________________________________________________________________________________
2.
ADDRESS - Street ______________________________________________________________________________________________________________________
City, State, Zip Code ____________________________________________________________________________________________________________________
3.
4.
5.
SOCIAL SECURITY
DATE OF BIRTH
GENDER
Male
Female
NUMBER ______________________________________
Month, Day, Year ___________________________
6.
I am a member of (check one)
Teachers’ Pension and Annuity Fund
Public Employees’ Retirement System
Police & Firemen’s Retirement System
State Police Retirement System
Judicial Retirement System
7.
______________________________________________________________
MEMBERSHIP #
8.
I hereby apply for enrollment in the Supplemental Annuity Collective Trust and authorize payroll deductions or reductions at the rate
and for the purpose indicated below.
Regular Deductions _______________%
or
Tax Sheltered Reduction _______________%
(Rates must be only whole percentages between 1% up to the maximum contribution allowable is the prevailing IRS maximum for all 403(b)
plans. A Salary Reduction Agreement must be in effect for those individuals who qualify for and elect the Tax Sheltered program.)
DESIGNATION OF BENEFICIARY
9.
I HEREBY NOMINATE:
NAME - Last, First, Middle ________________________________________________________________
RELATIONSHIP __________________________________
ADDRESS - Street __________________________________________________________________________________________________________________________
SOC. SEC. NO. OR
City, State, Zip Code ______________________________________________________
FEDERAL TAX ID NO. ________________________________________
DATE OF BIRTH - Month, Day, Year __________________________________________
GENDER
Male
Female
as the beneficiary who shall receive payment of any and all amounts due or to become due upon my death, IF LIVING:
OTHERWISE TO:
NAME - Last, First, Middle ________________________________________________________________
RELATIONSHIP __________________________________
ADDRESS - Street __________________________________________________________________________________________________________________________
SOC. SEC. NO. OR
________________________________
City, State, Zip Code ______________________________________________________
FEDERAL TAX ID NO.
DATE OF BIRTH - Month, Day, Year ___________________________________________
GENDER
Male
Female
In the absence of a specific request, if multiple beneficiaries are named, the following shall apply: “Share and share alike, survivors.” Please
note: Changes of beneficiary forms filed with the regular retirement system do not automatically change the beneficiary on file with the
Supplemental Annuity Collective Trust.
The benefit will be paid in a lump sum settlement. However, if the beneficiary is a natural person, he/she may elect to receive the benefit as
an annuity under one of the available options.
10. Signature of Applicant ________________________________________________
Date _________________________________
PART II — CERTIFICATION OF EMPLOYING AGENCY (Please complete applicable items)
I certify that the name, retirement system and membership number shown above are correct. I also certify that the member is currently
employed at an annual base salary of $ _______________________.
_______________________________________________________________________________________________
_______________________
_________________________
EMPLOYING AGENCY
PAYROLL NUMBER
LOCATION CODE NUMBER
_________________________________________
__________________________________________________________________________
______________________________
COUNTY
ADMINISTRATOR’S SIGNATURE
DATE
ENROLLMENT REQUEST CONFIRMATION — FOR DIVISION OF PENSIONS AND BENEFITS USE ONLY
_________________________________________
__________________________________________________________________________
______________________________
EFFECTIVE DATE
ADMINISTRATOR’S SIGNATURE
DATE
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