Form Uc-9a - Employee'S Claim For Refund Of Excess Contributions For The Calendar Year 2000

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MAIL TO:
DIVISION OF EMPLOYER ACCOUNTS, WORKER REFUND UNIT "99", PO BOX 076, TRENTON, NEW JERSEY 08625-0076
UC-9A (R-2-01)
SOCIAL SECURITY NUMBER:
State of New Jersey
Department of Labor
DIVISION OF EMPLOYER ACCOUNTS
EMPLOYEE'S
NAME:
EMPLOYEE'S CLAIM FOR
STREET
REFUND OF EXCESS CONTRIBUTIONS
ADDRESS:
FOR THE CALENDAR YEAR 2000
CITY, STATE
ZIP CODE:
PLEASE READ THE INSTRUCTIONS CAREFULLY ON THE REVERSE BEFORE COMPLETING THIS CLAIM
STATEMENT OF REFUND CLAIMANT
I hereby apply for a refund of worker contributions in excess of $42.40 for New Jersey Unemployment Insurance, in excess of $42.40 for New Jersey Health
Care Subsidy Fund, in excess of $5.30 for New Jersey Workforce Development Partnership Fund and in excess of $106.00 for New Jersey Disability
Insurance by reason of having received wages from two or more employers during the above calendar year and in support thereof, submit the following
statement of employer certifications of wages and deductions for Unemployment Insurance, New Jersey Health Care Subsidy Fund, Workforce
Development Partnership Fund and Disability Insurance. In addition, I have either been determined ineligible or have not applied for this refund as a credit
toward my New Jersey Gross Income Tax.
Date
Signature
STATEMENT OF EARNINGS
EMPLOYER'S NAME
CITY AND STATE
WAGES
$
(Use additional sheets, if necessary)
MAKE SURE THAT ALL CERTIFICATIONS ARE ATTACHED BEFORE FILING YOUR CLAIM
W.F. Refund
D. I. Refund
U. I. Refund
H. C. Refund
Total Refund

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