Transmittal Electronic Payment System (Teps) Employer Authorization And Change Form printable pdf download

Transmittal Electronic Payment System (Teps) Employer Authorization And Change Form

FB-0187-0615

STATE OF NEW JERSEY – DEPARTMENT OF THE TREASURY

DIVISION OF PENSIONS AND BENEFITS

TRANSMITTAL ELECTRONIC PAYMENT SYSTEM (TEPS)

EMPLOYER AUTHORIZATION AND CHANGE FORM

Please type or print all information clearly, verify that you have completed the form correctly, and retain a copy for your

records. Bank information changes must be accompanied by a copy of a check clearly marked “void.” Both this

completed form and the voided check (if applicable) should be faxed to 1-866-568-2495. You will receive confirmation

of your enrollment as well as your TEPS access instructions and password within one week.

For assistance on completing this form, see the instructions on page 2 or call the TEPS Helpline at 1-888-835-3345.

TYPE OF ATIVITY:

 ADD NEW ACCOUNT

 NOTICE OF CHANGE

 DELETE ACCOUNT



Payment System:

TPAF

PERS

PFRS

HEALTH BENEFITS

(Check only one)

Employer Location Number: ___ ___ ___ ___ ___ ___

(Must be 6 digits)

Employer Name (25): __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

(Limit 25 spaces)

Primary Contact:_________________________________________________________________________________________

Address:_______________________________________________________________________________________________

City:__________________________________________________

7. State:_________

8. Zip:_____________________

Primary Phone: (_____) _______ - ____________________ 10. E-mail Address:____________________________________

Secondary Contact:_______________________________________________________________________________________

12.

Secondary Phone: (_____) _______ - __________________ 13. Secondary E-mail:__________________________________

FINANCIAL INSTITUTION INFORMATION

(Please fax a voided check with this form.)

14.

Transit (Routing) / ABA Number: __ __ __ __ __ __ __ __ __

(Must be 9 digits)

15.

Account Number: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

(Up to 17 digits)

AUTHORIZATION:

I (we) hereby authorize the financial institution indicated above to debit the account listed in #15 above, and transfer the debited

amount to the Division of Pensions and Benefits. These transactions are to be accomplished in accordance with the procedures of

TEPS, for the Payment System listed in #1 above of the employer I (we) represent

APPROVAL: (Employer’s Certifying Officer)

CERTIFYING OFFICER NAME

TITLE

SIGNATURE

DATE

Return this completed form and, if applicable, a voided check — Fax to 1-866-568-2495

Transmittal Electronic Payment System (Teps) Employer Authorization And Change Form

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