Et-0547-0713 Report Of Transfer / Multiple Enrollment Form

NEW JERSEY DIVISION OF PENSIONS AND BENEFITS

ET-0547-0713

PO Box 295

Trenton, NJ 08625-0295

REPORT OF TRANSFER / MULTIPLE ENROLLMENT FORM

See reverse side for instructions on completing this form.

INDICATE TYPE OF ACTION:

REPORT OF TRANSFER

MULTIPLE ENROLLMENT

or

(PERS and TPAF Only)

INDICATE RETIREMENT SYSTEM:

Public Employees’ Retirement System (PERS)

Teachers’ Pension and Annuity System (TPAF)

Police and Firemen’s Retirement System (PFRS)

THIS SECTION TO BE COMPLETED BY THE MEMBER:

Social Security Number:________________________________ Pension Membership Number: _________________________________

Name:_________________________________________________________________________________________________________

Last

First

Middle

Maiden

Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Street

City

State

ZIP Code

Daytime Telephone: ___________________________________

Area Code

THIS SECTION TO BE COMPLETED BY NEW EMPLOYER:

Name of Former Employer:________________________________________________________________________________________

Date of Last Pension Deduction Reported by Former Employer:___________________________ Termination Date: _____/_____/_____

Month/Year

or

Pay Period/Year

Month / Day / Year

Name of New Employer:___________________________________________________________________________________________

New Employer Location/Payroll Number:____________________________ Is New Employer a Board of Education?

Yes

No

Title of New Position:___________________________________________ Date Current Employment Began: _____/_____/_____

Month

Day

Year

To be completed for TPAF applications only

Date Employment Began: _____/_____/_____ (Do not include temporary or substitute service)

Month

Day

Year

Does position require a New Jersey State Certificate issued by the State Board of Examiners within the NJ Department

of Education?

Yes

No

Does the applicant hold a certification issued by the State Board of Examiners within the NJ Department of Education?

Yes

No

For NJ Department of Education Only: Is the position Unclassified Professional?

Yes

No

Current Annual Base Salary: $_____________________ Employee is paid on:

10 month basis

12 month basis

Are the work hours fixed at 32 hours (Local) or 35 hours (State) or more per week pursuant to Ch.1, P.L.2010?

Yes

No

Is employee currently employed by more than one public agency?

Yes

No

I certify that this employee and position meets the eligibility criteria for the retirement system as provided by law. I further certify that I have

and Annual Membership Certification

successfully completed the online training

required by N.J.S.A. 43:3C-15. 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 Certifiying Officer

Print Name of Certifying Officer

__________/__________/_________

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Month

Day

Year

Telephone Number:

Area Code

Extension Number

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Street

City

County

State

ZIP Code

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Signature of Certifiying Officer’s Supervisor

Print Name of Certifying Officer’s Supervisor

__________/__________/_________

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Month

Day

Year

Telephone Number:

Area Code

Extension Number