Form Fl-0787-0216 Nj Dcrp Waiver Of Retirement Program Participation For Employees Enrolled In The Pers Or Tpaf (Page 2 of 2) in pdf

Form Fl-0787-0216 Nj Dcrp Waiver Of Retirement Program Participation For Employees Enrolled In The Pers Or Tpaf Page 2

FL-0787-0216

DCRP WAIVER FORM

CHAPTER 103, P.L. 2007

CHAPTER 1, P.L. 2010

INSTRUCTIONS

MEMBER INSTRUCTIONS

READ THE INFORMATION ABOUT WAIVER OF PARTICIPATION IN THE DCRP, then complete

the Certification and Signature section. By signing this Waiver Form you indicate that you understand

and agree to the conditions.

IN THE CERTIFICATION AND SIGNATURE SECTION:

Enter the Full Name of your Employing Entity and your Official Title or position.

Print your Name — Enter your full name (first, middle initial, and last name).

Enter your Social Security Number or your Pension ID Number

Sign and Date this Waiver Form. Unsigned waivers will be returned.

Submit the completed form to your employer.

EMPLOYER INSTRUCTIONS

IF WAIVING PARTICIPATION, this completed form must be certified by the employer and submitted

to the Division of Pensions and Benefits at the time employment commences.

RETURN THIS COMPLETED FORM TO:

DEFINED CONTRIBUTION RETIREMENT PROGRAM

New Jersey Division of Pensions and Benefits

PO Box 295

Trenton, New Jersey, 08625-0295

or fax to:

(609) 633-1696

Form Fl-0787-0216 Nj Dcrp Waiver Of Retirement Program Participation For Employees Enrolled In The Pers Or Tpaf Page 2