Et-0868-0812 Tier To Tier Transfer Form printable pdf download

ET-0868-0812

PO Box 295

NEW JERSEY DIVISION OF PENSIONS AND BENEFITS

Trenton, NJ 08625-0295

TIER-TO-TIER TRANSFER FORM

See reverse side for instructions on completing this form.

INDICATE RETIREMENT SYSTEM:

Public Employees’ Retirement System (PERS)

Teachers’ Pension and Annuity System (TPAF)

Police and Firemen’s Retirement System (PFRS)

THIS SECTION TO BE COMPLETED BY THE MEMBER:

1. Social Security Number:__________________________ 2. Pension Membership Number: _____________________

3. Name:________________________________________________________________________________________

Last

First

Middle

Maiden

4. Address:______________________________________________________________________________________

Street

_________________________________________________________________________________________

City

State

Zip Code

5. Daytime Telephone: ___________________________________

Area Code

Number

INACTIVE MEMBERSHIP:

6. Inactive Pension Membership Number:______________________________________

7. I Certify that I:

Resigned

Was dismissed with no appeal pending

Was dismissed with appeal pending

Was laid off

CHECK ONE

from my position as _____________________________________________________________

Title of Position

8. Date of Termination: _____/_____/_____ 9. Membership Tier of inactive membership:_____________________

Month

Day

Year

ACTIVE MEMBERSHIP:

10. New Employer:________________________________________________________

_______________________

New Employer Name

County

11. Membership Tier under current (active) membership:_________________________

I hereby apply for the transfer of my inactive membership to the active Membership Tier indicated above and authorize

payment of the withdrawal value of my account be made to that new Membership Tier subject to the statutes, rules, and

regulations of the retirement system. The transfer shall include all eligible pension service credit and corresponding

pension contributions.

•

I understand that once my Tier-To-Tier Transfer Form is submitted to the Division of Pensions and Benefits, I cannot

change my decision to transfer.

•

I understand that prior to submitting this form, I have the right to request a retirement estimate based on my inactive

pension membership.

•

By signing the Tier-To-Tier Transfer Form , I understand that I am irrevocably waiving all rights to any benefits provid-

ed to me under my inactive pension membership.

Signature of Applicant___________________________________________________

Date _____________________

Et-0868-0812 Tier To Tier Transfer Form

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