Application For Volunteer Emergency-Worker'S Survivors Pension (Vesp) Form
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2CV-0636-0803q
The State of New Jersey — Department of the Treasury
Division of Pensions and Benefits
Application for Volunteer Emergency-Worker's Survivors Pension (VESP)
INSTRUCTIONS
Part I and Part II are to be completed by the designated representative of the municipality. Include names of dependent
children even if spouse is living. See reverse side for eligibility criteria and definitions of a dependent.
Part III must be completed and signed by the municipality’s Certifying Officer.
PART I — VOLUNTEER WORKER INFORMATION
Volunteer's Name:__________________________________________________________________________________
LAST
FIRST
MI
Social Security Number:_________________________ Date of Birth:____/____/_____ Date of Death:_____/____/_____
MM
DD
YYYY
MM
DD
YYYY
Volunteer Title/Position:______________________________________________________________________________
Name of Volunteer Company or Squad:_________________________________________________________________
PART II — SURVIVOR INFORMATION
Name of Spouse:___________________________________________________________________________________
LAST
FIRST
MI
Social Security Number:_________________________________ Date of Birth:_____/_____/_____
MM
DD
YYYY
Address:_____________________________________________________ Phone: (______) ______________________
AREA CODE
_____________________________________________________
CITY
STATE
ZIP
Dependent Children (Must be disabled or under age 24)
1. Child’s Name:_________________________________________________________ In School?
Yes
No
LAST
FIRST
MI
Social Security Number:_____________________________________
Date of Birth:_____/_____/_____
MM
DD
YYYY
2. Child’s Name:_________________________________________________________ In School?
Yes
No
LAST
FIRST
MI
Social Security Number:_____________________________________
Date of Birth:_____/_____/_____
MM
DD
YYYY
3. Child’s Name:_________________________________________________________ In School?
Yes
No
LAST
FIRST
MI
Social Security Number:_____________________________________
Date of Birth:_____/_____/_____
MM
DD
YYYY
(Attach separate sheet to list additional children)
Dependent Parents (If no dependent spouse or children)
1. Parent’s Name:_____________________________________________________________________________
LAST
FIRST
MI
Social Security Number:_____________________________________
Date of Birth:_____/_____/_____
MM
DD
YYYY
1. Parent’s Name:_____________________________________________________________________________
LAST
FIRST
MI
Social Security Number:_____________________________________
Date of Birth:_____/_____/_____
MM
DD
YYYY
(Continued on other side)
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