Form Ee-0516-0611 Judicial Retirement System Enrollment Application
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2STATE OF NEW JERSEY – DEPARTMENT OF THE TREASURY
P.O. Box 295
EE-0516-0611
Trenton, NJ 08625-0295
DIVISION OF PENSIONS AND BENEFITS
JUDICIAL RETIREMENT SYSTEM
ENROLLMENT APPLICATION
DO NOT WRITE IN THIS BOX
LOCATION NO.
MEMBERSHIP NO.
APPLICANT INFORMATION (Please Print or Type – Instructions are on page 2 of this form)
1.
Name: _______________________________________________________________________________________
Last
First (no nicknames)
Middle
Maiden Surname and Surname Used During Previous Membership
2.
Address:__________________________________________________________________________________________________________________________
Street
City
State
Zip Code
3.
Date of Birth: _____/_____/_____
4. Social Security #: ___________________________
Month
Day
Year
(Copy of Birth Certificate or other proof must be attached)
5.
Daytime Phone: ( ____ ) ______—_____________
6. Gender
Male
Female
:
7a. Marital Status: ______________________________________________
7b. Date of Marriage/Civil Union: _____/_____/_____
Month
Day
Year
8.
Spouse/Partner’s Date of Birth: _____/_____/_____
Month
Day
Yea r
9a. Enter the name of any public retirement system in which you are or have been a member in this or any other
state:
9b. Enter the Membership #: ________________________________________
______________________________________
EMPLOYER INFORMATION (Please Print or Type)
750
ADMINISTRATIVE OFFICE OF THE COURTS
10. Employer Name: ________________________________________
11. Payroll Number: _____________
12. Title/Position of Applicant: ______________________________________________________________________________________________________
13. Date of Oath: _____/_____/_____
14. Annual Salary: $ _____________________________________________________________
Month
Day
Yea r
EMPLOYER CERTIFICATION
15. Name of Employer Representative Completing Application:______________________________________________
16. Phone Number: ( ______ ) ______—_____________ Ext.: ____________
I certify that this employee and position meets the eligibility criteria for the retirement system as provided by law.
I acknowledge that I am subject to penalty for falsifying or permitting to be falsified any record, application, form,
or report of the retirement system in an attempt to defraud the system pursuant to N.J.S.A. 43:3C-15.
(Two Signatures Required)
17. ______________________________________________________________________
Date: _____/_____/_____
Signature of Certifying Officer
Month
Day
Year
18. ______________________________________________________________________
Date: _____/_____/_____
Signature of Certifying Officer’s Supervisor
Month
Day
Year
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