Form Fl-0788-0510 Election To Participate In The Dcrp For Pers Or Tpaf Employees Who Previously Waived Dcrp Enrollment

PO BOX 295

State of New Jersey

FL-0788-0510

Trenton, NJ 08625-0295

Department of the Treasury

Division of Pensions and Benefits

NEW JERSEY DEFINED CONTRIBUTION RETIREMENT PROGRAM

ELECTION TO PARTICIPATE IN THE DCRP

FOR PERS, TPAF, PFRS, OR SPRS EMPLOYEES

WHO PREVIOUSLY WAIVED DCRP ENROLLMENT

(Please follow the instructions on page 2 of this form)

DO NOT WRITE IN THIS BOX LOCATION NO.

IDENTIFICATION NO.

1. Have you previously waived participation in the Defined Contribution Retirement Program?

Yes

No

(If “No”, do not use this form. See your employer about enrollment into the Defined Contribution Retirement Program.)

APPLICANT INFORMATION:

(Please Print or Type)

2. Name:

_____________________________________________________

3.Date of Birth: _____/_____/_____

First (no nicknames)

Middle

Last

Month

Day

Year

4. Social Security Number:___________________________________

5. Gender:

Male

Female

8. Are you receiving a benefit from a New Jersey State-

6. Daytime Phone: (_______) ________—_________________

administered or local New Jersey retirement system?

Yes

No

7. Address: ___________________________________________________________________

(If "Yes", please provide retirement system name)

Street

_____________________________________________________________________________

____________________________________________

City

State

Zip Code

EMPLOYER INFORMATION

(Please Print or Type):

9. Employer Name: __________________________________________________________________________________________

10. County: _______________________________________

11. PERS, TPAF, PFRS, or SPRS Location #: ________________________ Payroll #: _________________

State Loc Only

12. Date Employment Began: _______/______/________

Month

Day

Year

13. Current Annual Base Salary $ ____________________

14. Title/Position of Applicant: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _

15. Applicant’s Signature: ________________________________________________________

Date: _______/_____/______

By signing this form I acknowledge that I rescind my waiver and wish to begin participation in the Defined Contribution Retirement

Program. I also understand that once enrolled I cannot later waive participation in the DCRP while serving in this title or position.

EMPLOYER CERTIFICATION

16. Phone Number: ( ______ ) ______—_____________ Ext.: ____________

I certify that this employee and position meets the eligibility criteria for the retirement program under N.J.S.A. 43:15C-2.

17. Certifying Officer: ______________________________________________________________

Date: _____/_____/_____

Print Name

Signature

Month

Day

Year

NOTE: SEE INSTRUCTIONS FOR BENEFICIARY DESIGNATION INFORMATION