Form Dpf-721 - Intergovernmental Transfer Agreement - New Jersey State Civil Service Commission Page 2
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3RECEIVING JURISDICTION AGREEMENT
(TO BE COMPLETED ONLY BY THE APPOINTING AUTHORITY)
1.
This intergovernmental transfer agreement in addition to all documents required to effectuate the transfer must be received by CSC at least
seven (7) days prior to the effective date of the transfer.
2.
Employees shall retain all accumulated seniority rights and sick time, except for those transferring in the title of Firefighter. A Waiver
of such rights shall be afforded to those in Law Enforcement titles and must be agreed upon with written consent from the receiving
authority, the affected employee, and the Civil Service Commission. A signed Law Enforcement Waiver
is
is not
attached.
3.
Vacation leave balances, administrative, personal or other types of leave will not be carried forward by the transferee. The transferee will
be paid, on a pro-rated basis, for vacation time earned prior to the transfer.
4.
Continuation of payments into the New Jersey Department of the Treasury, Division of Pensions and Benefits Retirement System, without
interruption, is mandatory.
5.
Is the transferee transferring to a title that has been designated to the Police and Fire Retirement System?
YES
NO
6.
If you answered yes above, has it been verified that the transferee meets the eligibility requirements set forth in N.J.S.A 40A:14-127 for
enrollment into the Police and Fire Retirement System?
YES
NO
7.
The transferee will receive a health benefits package pursuant to the jurisdiction policy.
8.
The affected union has been informed of this transfer by the receiving jurisdiction.
9.
The requested title is: _________________________________________________; to be compensated at $ _________________ annually.
10. If there is an existing residency ordinance, a waiver of residency requirements has been approved for this transferee.
CONTACT INFORMATION (Please Print):
_______________________________________________________________________________________
ADDRESS
_________________________________________________________________________
(______) _____________________.
CITY / STATE / ZIP
TELEPHONE
__________________________________________________________________________ (______) _____________________
EMAIL ADDRESS
FAX
This transfer has been
Approved
Proposed Effective Date: ____________________________________________.
Appointing Authority (Authorized Name and Signature of Authority as listed with CSC):
____________________________________________________, ___________________________________________
Authorized AA Name
Title
_____________________________________________________________________
_______________________
Signature of Approval
Date
NEW JERSEY CIVIL SERVICE COMMISSION
AUTHORIZATION OF INTERGOVERNMENTAL TRANSFER
1.
This individual, having met all the conditions for an Intergovernmental Transfer, is granted a change to the following;
title: __________________________________________________ title code: ____________ from the title code of: _____________.
2.
A Law Enforcement Waiver for the following is attached:
Waiver of all accumulated seniority
Waiver of all accrued sick leave
3.
The appointment type for this Intergovernmental Transfer is: ___________________________________________.
4.
A Working Test Period (WTP):
WILL
WILL NOT be necessary.
5.
Conditions/Comments: _____________________________________________________________________________________________.
This transfer has been:
APPROVED
DISAPPROVED
____________________________________________________________
____________________________________
______________
CSC Authorized Signature
Title
Date
DPF-721 Revised 5/30/12
Page 2 of 2
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