Form Fl-0781-0511 Nj Dcrp Enrollment Application

State of New Jersey

FL-0781-0511

PO BOX 295

Department of the Treasury

Trenton, NJ 08625-0295

Division of Pensions and Benefits

NEW JERSEY DEFINED CONTRIBUTION RETIREMENT PROGRAM

ENROLLMENT APPLICATION

FOR ELECTED OR APPOINTED OFFICIALS

(Please follow the instructions on page 2 of this form)

DO NOT WRITE IN THIS BOX LOCATION NO.

IDENTIFICATION NO.

APPLICANT INFORMATION:

(Please Print or Type)

1. Name:

________________________________________________________________________________________________

First (no nicknames)

Middle

Last

2. Social Security Number: _________________________________________________

3. Date of Birth: _____/_____/_____

Month

Day

Year

4. Gender:

Male

Female

5.

Daytime Phone: (_______) ________—_________________

6. Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Street

City

State

Zip Code

7. Is the applicant receiving a benefit from a New Jersey State-administered or local New Jersey retirement system at this time?

Yes

No (If "Yes", please provide retirement system name) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

EMPLOYER INFORMATION (Please Print or Type)

:

8. Employer Name: __________________________________________________________________________________________

9. County: _______________________________________

10. PERS or TPAF Location #: ________________________ Payroll #: _________________

State Loc Only

11. Date Elected or Appointed Service commenced: _______/______/________

Month

Day

Year

12. Current Annual Base Salary $ ____________________

1

3. Title/Position of Applicant: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

14. Is the applicant an Elected Official?

Yes

No

15. Is the applicant appointed by Special Resolution or Ordinance or by the Governor of New Jersey, as described in

N.J.S.A. 43:15C-2?

Yes

No

EMPLOYER CERTIFICATION

16. Phone Number: ( ______ ) ______—_____________ Ext.: ____________

17. 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)

_______________________________________________

__________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Signature of Certifying Officer

Title

Date

_______________________________________________

__________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Signature of Certifying Officer’s Supervisor

Title

Date

NOTE: SEE INSTRUCTIONS FOR BENEFICIARY DESIGNATION INFORMATION