Form Fl-0787-0216 Nj Dcrp Waiver Of Retirement Program Participation For Employees Enrolled In The Pers Or Tpaf

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FL-0787-0216
CHAPTER 103, P.L. 2007
State of New Jersey
PO BOX 295
CHAPTER 1, P.L. 2010
Trenton, NJ 08625-0295
Department of the Treasury
Division of Pensions and Benefits
NEW JERSEY DEFINED CONTRIBUTION RETIREMENT PROGRAM
WAIVER OF RETIREMENT PROGRAM PARTICIPATION
FOR EMPLOYEES ENROLLED IN THE PERS, TPAF, PFRS, OR SPRS
EARNING SALARY IN EXCESS OF THE SOCIAL SECURITY MAXIMUM
(Please follow the instructions on page 2 of this form)
EMPLOYEES ENROLLED IN THE PERS, TPAF, PFRS, OR SPRS
(Read and sign below)
As a member of PERS, TPAF, PFRS, or SPRS deemed eligible and required to participate in the Defined
Contribution Retirement Program (DCRP) based upon salary exceeding the Social Security Maximum,
under Chapter 103, P.L. 2007 (N.J.S.A. 18A:66-2 et seq. and N.J.S.A. 43:15A-6 et seq.) and Chapter 1,
P.L. 2010 (N.J.S.A. 43:16A-1 et seq. and N.J.S.A. 53:5A-3 et seq.), I elect to waive participation in the
DCRP with regard to my current eligible employment.
I acknowledge that this written waiver filed with the Division of Pensions and Benefits waives all rights
and benefits that would otherwise be provided by the DCRP.
I understand that I may thereafter elect to participate in the retirement program by filing with the Division
of Pensions and Benefits, an Election To Participate In the DCRP form. Such election shall commence
on the first day of January following the filing of the election to participate.
CERTIFICATION AND SIGNATURE
(Must be completed to waive participation.)
By signing this form, I acknowledge that I am waiving all rights and benefits that would otherwise be provided
by the Defined Contribution Retirement Program with regard to my employment or position with:
__________________________________________ as __________________________________________.
Name of Employer
Title
_______________________________________________
_______________________________
Member’s Name (Please Print)
Social Security Number or Pension ID Number
_______________________________________________
_______________________________
Signature
Date
EMPLOYER CERTIFICATION
I certify that this employee and the position listed meet the eligibility criteria for the retirement program under
N.J.S.A. 43:15C-2 and that the employee has voluntarily elected to waive participation.
Certifying Officer: _________________________________________________ Date: _____/_____/_____
Print Name
Signature
Month
Day
Year
Phone Number: (______) ______-_____________ Ext.: ____________ Location No.: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

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