Form Cw-0606-0709 Employer'S Certification For Withdrawal (Page 2 of 2) in pdf

Form Cw-0606-0709 Employer'S Certification For Withdrawal Page 2

CW-0606-0709

INSTRUCTIONS FOR COMPLETING THE EMPLOYER’S CERTIFICATION

This certification must be completed by the employer when a member files for the withdrawal

of pension contributions. Failure to provide this information will delay processing of the

member's Application for Withdrawal. If you need assistance in completing this certification,

call the Division of Pensions and Benefits, Office of Client Services at (609) 292-7524.

ITEMS REQUIRING SPECIAL ATTENTION

REASON FOR LEAVING

You must indicate the member’s reason for leaving. Place an (X) the box next to “resigned,” or if the member was

dismissed, you must also indicate with an (X) if the dismissal has an appeal pending or no appeal pending. This infor-

mation is required before processing the withdrawal application.

TERMINATION DATE

A member must terminate employment before this certification can be submitted to the Division of Pensions and

Benefits. Include the date of termination and the date of the last pension deduction. State biweekly reporting agen-

cies must enter the number and year of the last pay period of the last pension deduction. All other employ-

ers must enter the month and year of the last pension deduction.

WORKER’S COMPENSATION

Please indicate if the member was receiving periodic benefits under a claim filed for Worker’s Compensation. Place

an (X) in the block to indicate if the member IS or IS NOT receiving these benefits. You must also indicate with an

(X) if the member DOES or DOES NOT have a Worker’s Compensation claim or litigation pending. This information

is required before processing the withdrawal application.

SALARY DEDUCTIONS

Indicate the following: (1) quarter ending, (2) amount of monthly base salary subject to contributions, (3) full rate of

contribution, (4) the dollar amount of the deduction, (5) loan repayment amount (if any), (6) back deductions, (7)

arrears or purchase deductions, (8) the total pension contributions (include all deductions for the quarter), and (9)

answer “yes” or “no” to whether the member contributed to the Supplemental Annuity Collective Trust (SACT).

SUBMIT THIS CERTIFICATION TO: WITHDRAWAL SECTION

DIVISION OF PENSIONS AND BENEFITS

PO BOX 295

TRENTON NJ 08625-0295

Form Cw-0606-0709 Employer'S Certification For Withdrawal Page 2