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