Form Nj-2450 - Employee'S Claim For Credit - 2016

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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 2016
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 contri-
butions.
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 LEAVE
UI/WF/SWF
DISABILITY
UI/WF/SWF, disability insurance, or Family Leave Insurance, insert the maximum in
INSURANCE
DEDUCTED
INSURANCE
the appropriate Column(s) and contact that employer for a refund of the balance of the
DEDUCTED
DEDUCTED
deduction.
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.
138.56
65.20
26.08
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 52 of the NJ-1040.
5.
Deduct Line 3 Col. B from Line 2 Col. B. Enter on Page 3, Line 53 of the NJ-1040.
6. Deduct Line 3 Col. C from Line 2 Col. C. Enter on Page 3, Line 54 of the NJ-1040.
I hereby apply for a credit for worker contributions deducted in excess of $138.56 for N.J. UI/WF/SWF and/or in excess of $65.20 for NJ Disability
Insurance and/or in excess of $26.08 for NJ Family Leave Insurance deductions by reason of having received wages from two or more employers dur-
ing the above calendar year and hereby submit the following statement of wages and deductions.
Claimant’s Signature: ______________________________________________________________ Date: _________________________________

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