Form Ee-0904-0814 Notification Of Employment After Retirement
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2EE-0904-0814
STATE OF NEW JERSEY
DIVISION OF PENSIONS AND BENEFITS
NOTIFICATION OF EMPLOYMENT AFTER RETIREMENT
DO NOT WRITE IN THIS BOX
LOCATION NO.
MEMBERSHIP NO.
THIS FORM IS TO BE COMPLETED BY THE EMPLOYER AND TO BE USED WHEN HIRING ANYONE WHO IS COLLECTING A
-
.
RETIREMENT BENEFIT FROM ANY NJ STATE
ADMINISTERED RETIREMENT SYSTEM
EMPLOYEE INFORMATION:
(Please print and follow the instructions on page 2 of this form.)
1. Name: _______________________________________________________________________________________
Last
First (no nicknames)
Middle
2. Address:___________________________________________________________________________________________________________________________
Street
City
State
Zip Code
3b. Retirement Type: ¨ Disability ¨ Other
3a. Retirement # or Former Membership #: ________________
4. Gender: ¨ Male ¨ Female
5. Date of Birth: _____/_____/_____
6. Daytime Phone: ( _____ ) ______ - _____________
Month
Day
Year
7a. Indicate employee’s date of retirement: _____/_____/_____
7b. Employer at Retirement : _________________
Month
Day
Year
EMPLOYMENT AFTER RETIREMENT INFORMATION
8. Employer Name: ________________________________________________________________________________
9. County: ______________________ 10. Location #: ____________ Bureau #: ___________ Payroll #: ___________
If Applicable
State Only
11. Title/position currently held by employee: ____________________________________________________________
¨ Annual Salary $____________
¨ Hourly wages: $____________
12. Indicate the employee’s earnings (
check one) :
¨ Full time
¨ Part-time
13. Describe the type of service:
If part-time, indicate hours pers week: ____________
14a. Date employment began: ____/____/____ 14b. Date employment is expected to end, if known: ____/_____/____
Month
Day
Year
Month
Day
Year
EMPLOYER CERTIFICATION
15. If the applicant retired from your location, did he/she complete a 180-day “bona fide severance of employment?”
¨ Yes ¨ No (If the applicant did not retire from your location, leave blank and continue to Item 16.)
Was there an agreement regarding employment after retirement for any position, paid or volunteer, at or about the
16.
¨ Yes ¨ No If yes, indicate date if known: _____/_____/_____
time of the employee’s retirement?
Month
Day
Year
I certify that the above information is accurate. 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).
17. ____________________________________________________________________ Date: ______/______/_____
Signature of Certifying Officer
Month
Day
Year
18. ____________________________________________________________________ Date: ______/______/______
Signature of Certifying Officer’s Supervisor
Month
Day
Year
19. Phone Number of Certifying Officer: ( _____ ) _______ - _____________ Ext.: ____________
NOTE: THIS NOTIFICATION MUST BE SUBMITTED WITHIN 15 CALENDAR DAYS OF EMPLOYMENT TO
THE ATTENTION OF THE EXTERNAL AUDIT UNIT,
DIVISION OF PENSIONS AND BENEFITS, PO BOX 295, TRENTON, NJ 08625-0295
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