Transmittal Electronic Payment System (Teps) Employer Authorization And Change Form (Page 2 of 2) in pdf

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STATE OF NEW JERSEY – DEPARTMENT OF THE TREASURY

DIVISION OF PENSIONS AND BENEFITS

TRANSMITTAL ELECTRONIC PAYMENT SYSTEM (TEPS)

EMPLOYER AUTHORIZATION AND CHANGE FORM

INSTRUCTIONS

This form is to be used for first-time enrollment in TEPS and also to make changes to your TEPS enrollment information.

ADD NEW ACCOUNT:

For employers registering for a new payment system in the TEPS program.

NOTICE OF CHANGE:

Used by employers to change the TEPS information on file, e.g., new address, different financial

institution ABA and/or account, additional retirement ACH account combination, etc.

DELETE ACCOUNT:

Submitted to terminate TEPS participation for a particular retirement system.

You must complete ALL items on the form. Omitted or illegible information in any section will automatically prohibit

processing and guarantee the immediate return of your form for proper completion.

1. PAYMENT SYSTEM:

Check the appropriate payment system. A separate Authorization Form must be completed

for each payment system and location number.

2. EMPLOYER LOCATION

Your 6-digit Location Number. TPAF accounts with 3 or 4 digits must include leading

NUMBER:

zeros (i.e. 100xxx or 10xxxx).

3. EMPLOYER NAME:

Please use the spaces (up to 25 characters) to print/type the name exactly as it should

appear for presentation of the ACH item to the financial institutions.

Name of the individual designated as the primary TEPS contact, who can be contacted in

4. PRIMARY CONTACT:

the event of questions concerning this form or future payments.

5. ADDRESS:

6. CITY:

Please indicate the correct mailing address for proper delivery of all TEPS correspondence.

Please include the two-digit state abbreviation and your 5-digit zip or 9-digit (zip+4) code.

7. STATE:

8. ZIP CODE:

9. PRIMARY CONTACT PHONE:

The direct telephone number of the primary contact named in item # 4.

10. PRIMARY CONTACT E-MAIL:

The e-mail address of the primary contact named in item # 4.

11. SECONDARY CONTACT:

Name of the individual designated as the secondary TEPS contact, who can be contacted in

the event of questions concerning this form or future payments.

12. SECONDARY CONTACT PHONE:

List the direct telephone number of the secondary contact.

List the e-mail address of the secondary contact.

13. SECONDARY CONTACT

E-MAIL:

14. FINANCIAL INSTITUTION

The 9-digit ABA/Transit Routing Number used to identify the financial institution at which

TRANSIT/ABA NUMBER:

the employer maintains their account. This number appears in the bottom line of the

checks.

The account identification number used to fund your transmittal (up to 17 digits). This

15. ACCOUNT NUMBER:

must be a checking account.

AUTHORIZATION AND APPROVAL

The Certifying Officer must sign and date this area.

OF CERTIFYING OFFICER:

Please fax the completed form to: 1-866-568-2495. You will receive confirmation of your enrollment as well as your TEPS

access instructions and password within one week.

Transmittal Electronic Payment System (Teps) Employer Authorization And Change Form Page 2

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