Form Et-0343-0713 Application For Interfund Transfer

ADVERTISEMENT

ET-0343-0713
State of New Jersey
Department of the Treasury — Division of Pensions and Benefits
PO Box 295, Trenton, NJ 08625-0295
APPLICATION FOR INTERFUND TRANSFER
This application must be completed by you and your former employer. This application must be filed with a new Enrollment Application for the
Retirement System to which you are transferring.
PART 1 —
Check one:
Transfer to Teachers' Pension and Annuity Fund
Transfer to State Police Retirement System
Transfer to Public Employees' Retirement System
Transfer to Judicial Retirement System
Transfer to Police and Firemen's Retirement System
1. Print Full Name _______________________________________________________ 2. Membership No.__________________________
3. Address ________________________________________________________________________________________________________
STREET
CITY
STATE
ZIP CODE
4. Currently a member of the _________________________________________________________________________________________
NAME OF RETIREMENT SYSTEM
5. Resigned, Was dismissed, ______________________________ from my position as __________________________________________
CIRCLE ONE
OTHER
TITLE OF POSITION
6. Date of termination
_____________________________________________
(MM/DD/YYYY)
7. NEW EMPLOYER
________________________________________________________________________________________________
NEW EMPLOYER NAME
COUNTY
8. I hereby apply for the transfer of my membership to the retirement system indicated above and authorize payment of the withdrawal value of
my account to be made to that system subject to the statutes, rules and regulations of that system. I understand that once my Application
for Interfund Transfer is submitted to the Division of Pensions and Benefits, I cannot change my decision to transfer.
Signature of Applicant __________________________________________________
Date ____________________________________
PART II — CERTIFICATION OF FORMER EMPLOYING AGENCY
Certifying Officer: In order to avoid delay in honoring this transfer, your certification will be used to calculate the payment due.
resigned
position abolished / laid off
was dismissed (no appeal pending)
I hereby certify that ________________________________________________
was dismissed (appeal pending)
NAME OF MEMBER
from this department, agency, or school district on _______________________________________. The last salary deduction was made on
DATE OF SEPARATION
___________________________________________ for ______________________________________. The employee's annual base salary
DATE
MONTH
YEAR
prior to resignation/dismissal was $_____________________________________________________.
I further certify that the following deductions have been made from his/her salary during the last two quarterly periods ending with the current quarter
(see QUARTERLY REPORT OF CONTRIBUTIONS). Biweekly reporting agencies should attach a screen print of TREADHOC biweekly certification
with salary projected until termination date.
Base Salary
Subject to
Back Deductions
Arrears
Total
Supplemental Annuity
Quarter
Contributions
Pension
Loan
and/or
Pension
Ending
This Quarter
Contribution
Repayment
No. Payments
Amount
Purchases
Deductions
% Rate
$ Amount
I certify that this employee and position met the eligibility criteria for the retirement system as provided by law. I further certify that I have successfully
completed the online training and Annual Membership Certification required by N.J.S.A. 43:3C-15. I acknowledge that I am subject to penalty for falsify-
ing 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
PRINT NAME OF CERTIFYING OFFICER
DATE
_____________________________________________________________
__________________________________________________
TITLE
EMPLOYING AGENCY
_____________________________________________________________
__________________________________
____________
COUNTY
PHONE NUMBER
EXTENSION
_________________________________________________
____________________________________
_________________________
SIGNATURE OF CERTIFYING OFFICER’S SUPERVISOR
PRINT NAME OF CERTIFYING OFFICER’S SUPERVISOR
DATE
_____________________________________________________________
__________________________________
____________
TITLE
PHONE NUMBER
EXTENSION

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Financial
Go