Form Cw-0606-0709 Employer'S Certification For Withdrawal printable pdf download

CW-0606-0709

State of New Jersey — Department of the Treasury

Division of Pensions and Benefits, PO Box 295, Trenton, NJ 08625-0295 — (609) 292-7524

EMPLOYER’S CERTIFICATION FOR WITHDRAWAL

THIS FORM MUST BE COMPLETED BY FORMER EMPLOYER

1. Name of Member __________________________________________________________________________

2. Membership No. __________________________

3. Social Security No. __________________________

This certification will be used to calculate the payment due to the member.

DO NOT COMPLETE THIS FORM UNTIL THE LAST DEDUCTION FROM SALARY HAS BEEN MADE.

resigned

I certify that _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

was dismissed (no appeal pending)

NAME OF FORMER EMPLOYEE

was dismissed (appeal pending)

from this organization on __________________. The last pension deduction was made _______________________________.

DATE

BIWEEKLY PAY PERIOD / YEAR OR

MONTH/ YEAR*

*State employers must enter the number of the pay period and the year of the last pension deduction.

All other employers must enter the month and year of the last pension deduction and be sure to sub-

mit that deduction for the entire month.

The employee

IS, or

IS NOT receiving periodic benefits under a claim filed for Workers’ Compensation based on an

injury incurred as a result of service performed in public employment and

DOES, or

DOES NOT have a Workers’ Com-

pensation claim or litigation pending.

CERTIFICATION OF SALARY DEDUCTIONS

ONLY TO BE COMPLETED FOR ANY UNPOSTED PENSION CONTRIBUTIONS

I certify that the following deductions have been made from the employee's salary during the last two quarterly periods ending

with the current quarter. State biweekly reporting agencies must attach a completed Supplemental Biweekly Certification of

Employing Agency or a screen print of the Centralized Payroll History screen in lieu of completing this item.

BASE SALARY

SUBJECT TO

FULL

ARREARS

TOTAL

QUARTER

CONTRIBUTIONS

RATE

PENSION

LOAN

BACK

AND/OR

PENSION

SACT

ENDING

THIS QUARTER

(%)

CONTRIBUTION

REPAYMENT

DEDUCTIONS

PURCHASES

CONTRIBUTIONS

YES OR NO

Signature of

Certifying Officer _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Date _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Employing Agency _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Telephone Number (______) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

(AREA CODE)

Form Cw-0606-0709 Employer'S Certification For Withdrawal

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