Form Nj-2450 - Employee'S Claim For Credit - 2010

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EMPLOYEE’S CLAIM FOR CREDIT
NJ-2450
FOR EXCESS UI/WF/SWF, DISABILITY INSURANCE, AND/OR
FAMILY LEAVE INSURANCE CONTRIBUTIONS FOR CALENDAR YEAR 2010
Claimant Social Security No.
Name:
Note on Joint NJ-1040 Return:
Address:
Each spouse/CU partner must file a separate
form when claiming a refund for excess
contributions.
City, State, Zip Code:
To establish a right to this credit, claimants are required to complete the items below (information is to be transcribed from W-2 forms enclosed with
your New Jersey State Income Tax return). Any items not substantiated by a W-2 or any information that is incomplete will cause the claim to be
rejected. The amount withheld for the Unemployment Insurance/Workforce Development/Supplemental Workforce Funds, disability insurance, and
the amount of Family Leave Insurance withheld must be reported separately on all W-2 statements.
TAKE ALL INFORMATION FROM YOUR W-2 FORMS.
COLUMN A
COLUMN B
COLUMN C
If the amount deducted by any one employer exceeds the maximum for either
FAMILY
UI/WF/SWF
DISABILITY
UI/WF/SWF, disability insurance, or Family Leave Insurance, insert the maximum in
LEAVE
DEDUCTED
INSURANCE
the appropriate Column(s) and contact that employer for a refund of the balance of the
INSURANCE
DEDUCTED
deduction.
DEDUCTED
1A. Employer’s Name:
Fed. Emp. I.D. #:
Private Plan #:
Wages:
B. Employer’s Name:
Fed. Emp. I.D. #:
Private Plan #:
Wages:
C. Employer’s Name:
Fed. Emp. I.D. #:
Private Plan #:
Wages:
D. Employer’s Name:
Fed. Emp. I.D. #:
Private Plan #:
Wages:
E. Employer’s Name:
Fed. Emp. I.D. #:
Private Plan #:
Wages:
F. Employer’s Name:
Fed. Emp. I.D. #:
Private Plan #:
Wages:
G.
*If additional space is required, enclose a rider and enter the total on this line
2.
Total Deducted: Add Lines 1A through 1G. Enter here.
3.
126.22
148.50
35.64
Correct UI/WF/SWF, Disability Insurance, and/or Family Leave Deductions
4.
Deduct Line 3 Col. A from Line 2 Col. A. Enter on Page 3, Line 51 of the NJ-1040.
5.
Deduct Line 3 Col. B from Line 2 Col. B. Enter on Page 3, Line 52 of the NJ-1040.
6. Deduct Line 3 Col. C from Line 2 Col. C. Enter on Page 3, Line 53 of the NJ-1040
I hereby apply for a credit for worker contributions deducted in excess of $126.22 for N.J. UI/WF/SWF and/or in excess of $148.50 for NJ Disability
Insurance and/or in excess of $35.64 for NJ Family Leave Insurance deductions by reason of having received wages from two or more employers during
the above calendar year and hereby submit the following statement of wages and deductions.
Claimant’s Signature: ______________________________________________________________ Date: _________________________________

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