Form Dpf-279 - Application For Lump Sum Supplemental Compensation For Earned And Unused Sick Leave For Retirees - Civil Service Commission

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S C O R
S C O R
S C O R
S C O R
S C O R
DPF-279
Lump Sum Supplemental Compensation for
APPLICATION FOR
Earned and Unused Sick Leave for Retirees
INSTRUCTIONS:
Before completing this form, see NJAC4A:6-3.(1 through 4) concerning SCOR.
1. NAME OF EMPLOYEE (Print or Type)
2. DEPARTMENT OR AGENCY
3. SIGNATURE OF EMPLOYEE
4. SOCIAL SECURITY NUMBER
5. PRESENT MAILING ADDRESS (Street, City, State, Zip Code)
6. EMPLOYEE’S TITLE AT RETIREMENT
Career
Senior Executive
Unclassified
Full Time
Part Time _________ %
7. Salary at time of retirement:
8. Effective date of Retirement:
10. DATES OF EMPLOYMENT
from:
to:
9. Name of Employee’s Pension System:
PERS
PFRS
TPAF
Leaves without pay; list dates, if any:
from:
to:
OTHER:
PENSION
from:
to:
NUMBER:
11. TOTAL AVERAGE ANNUAL COMPENSATION
(Base salary during last 261 paid payroll days or 217 days for 10 month employees, counting
back from effective date of retirement). Be sure to exclude any unpaid leaves.
TITLE
PERIOD (Day, Month, Year)
Number of Payroll Days X Daily Rate = Amount
from:
to:
$
from:
to:
$
from:
to:
$
from:
to:
$
from:
to:
$
$
Total Days
261
or
217
Total Compensation
12. AVERAGE DAILY RATE DURING LAST
13. UNUSED SICK LEAVE
(When converting hours to days,
DAYS
14. AMOUNT
round out figures to nearest quarter of day)
FULL YEAR OF EMPLOYMENT:
A. For 12-month employees
$ _________
(Item 13E X Item 12
A. Balance thru December 31, ____________ (Prior Year)
divide total compensation
divided by 2)
B. Earned calender year __________ to effective date of retirement
(Item 11) by 261.
(Employees earn 1.25 days per month)
$
C. Total sick days accrued (A + B)
$ _________
B. For 10-month employees
NOTE: Total payment
D. Used calender year ____________ to effective date of retirement
divide total compensation
NOT to exceed $15.000
E. Balance of sick leave at retirement (C minus D)
(Item 11) by 217.
15. Sick leave information for UNCLASSIFIED service or any periods served in unclassified service. Please attach sick leave time records for last 5 years of unclassified service.
YES
NO
A. Was there a fixed number of
D. Give dates for which sick leave records were main-
F. Has this employee or employees in these class titles,
tained and are available (Indicate month, day, and year)
days an employee could earn and
received types or amounts of leave that classified
be credited each year?
How many? __________
employees did not receive?
from:
to:
Explain how this amount was determined on reverse side.
YES
NO
from:
to:
B. Was sick leave recorded in the same manner for all full
time employees?
If YES, what types of leave and how much of each was
YES
NO
E. On reemployment, did former employee regain
granted? Explain variations from procedure for classified
sick leave outstanding at the time of separation?
Explain how recorded on reverse side.
employees. Use reverse side for explanations.
YES
NO
C. Are records concerning use of sick leave maintained?
(If YES, were there any limitations)
YES
NO
(If YES, describe
YES
NO
Explain how maintained on reverse side.
limitations on reverse)
16.
I CERTIFY that all statements on this application are true and correct to the best of my knowledge and belief under penalty of perjury.
Signature of Appointing Authority
Date:
17. APPROVAL: Civil Service Commission
Submit completed
Civil Service Commission
form along with
Compensation/SCOR Unit
pension approval
P.O. Box 313
letter to
Trenton, NJ 08625
Signature
Date:
DPF-279 Revised 09-04-09

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