The EE-0681-0710 form plays a crucial role in the New Jersey Division of Pensions and Benefits, serving as a comprehensive enrollment platform for incoming members. Designed to cater to applicants of both the Teachers' Pension and Annuity Fund and the Public Employees' Retirement System, this document meticulously gathers essential personal and employment information. Applicants are guided through a detailed process, starting from basic personal identification to more specific employment details, such as position, date of employment commencement, and pertinent salary information. Moreover, the form addresses the need for differentiation between various employment statuses, such as temporary or provisional positions, and specifies requirements unique to teachers and public employees. Additionally, it probes into eligibility criteria, such as the number of hours worked and the nature of the employment contract, paving the way for a seamless integration into the respective pension fund. The structured layout of the form, complemented by clear instructions, ensures that applicants can provide the necessary information with accuracy, thereby streamlining the enrollment process. Significantly, the form embodies a multilayered approach to pension fund enrollment, combining rigorous data collection with user-friendly design, to ensure compliance and facilitate a smooth transition for new members.
| Question | Answer |
|---|---|
| Form Name | Form Ee 0681 0710 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | Ext, 2007, EE-0681-0710, appointees |
New Jersey Division of Pensions and Benefits
ENROLLMENT APPLICATION |
||
|
||
|
|
|
DO NOT WRITE IN THIS BOX |
LOCATION NO. |
MEMBERSHIP NO. |
|
|
|
APPLICANT INFORMATION: (Please Print or Type and follow the instructions on page 2 of this form)
Select Pension Fund: (Check one) Teachers' Pension and Annuity Fund Public Employees' Retirement System
1.Name: ___________________________________________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
|
Last |
First (no nicknames) |
Middle |
Maiden Surname and Surname Used During Previous Membership |
|||
2. |
Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ |
||||||
|
|
Street |
|
City |
|
State |
Zip Code |
3. |
Social Security #: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ |
4. Gender: Male |
Female |
||||
5. |
Date of Birth: _____/_____/_____ |
6. Daytime Phone: ( ______ ) |
|
||||
7.Is the applicant receiving a benefit from a New Jersey
Yes No (If "Yes", please provide retirement system name) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
EMPLOYER INFORMATION (Please Print or Type):
8.Employer Name: __________________________________________________________________________________________
9. County: ________________________ 10. Location #: ______________ Bureau #: ____________ |
Payroll #: _____________ |
If Applicable |
State Loc Only |
11.Title/Position of Applicant: ___________________________________________________________________________________
12. Is the applicant currently employed by more than one public employer? Yes No
|
(If "Yes", please provide name of employer(s)) |
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ |
|
||
TO BE COMPLETED FOR TPAF APPLICATIONS ONLY |
||
13 |
(a.) Date Employment Began: _____/_____/_____(Do not include temporary or substitute service) |
|
|
Month Day |
Year |
13 |
(b.) Does position require a New Jersey State Certificate issued by the State Board of Examiners within the NJ Department of |
|
|
Education? Yes No |
|
13 |
(c.) Does the applicant hold a certification issued by the State Board of Examiners within the NJ Department of Education? |
|
Yes No
13 |
(d.) For NJ Department of Education Only: Is the position Unclassified Professional? Yes No |
|
|
||||
TO BE COMPLETED FOR PERS APPLICATIONS ONLY |
|
|
|
|
|||
14 |
(a.) Date Employment Began: _____/_____/_____ 14 (b.) Date of Regular or Permanent Appointment: _____/_____/_____ |
||||||
|
|
Month |
Day Year |
|
Month |
Day |
Year |
14 |
(c.) Is the applicant still considered temporary or provisional? |
Yes No |
|
|
|||
15. Is the applicant an elected official? |
Yes No |
|
|
|
|
||
16. |
Is the applicant appointed by Special Resolution or Ordinance or by the Governor with Senate confirmation? |
Yes |
No |
||||
17. |
Has the applicant been awarded a professional services contract? |
Yes No |
|
|
|||
|
|
|
|||||
18. Current Annual Base Salary $ ____________________ |
19. |
(Check one) |
|||||
20. |
Are the work hours fixed at 32 hours (Local) or 35 hours (State) or more per week pursuant to Ch.1, P.L. 2010? Yes No |
||||||
EMPLOYER CERTIFICATION |
|
|
|
|
|
||
21.Name of Human Resources Representative Completing Application: __________________________________________________
22.Phone Number: ( ______ )
By signing this application, I am certifying under penalty of perjury, to the truthfulness of the information contained herein.
23. Certifying Officer: ______________________________________________________________ |
Date: _____/_____/_____ |
|
Print Name |
Signature |
Month Day Year |
NOTE: IF THIS APPLICATION IS NOT SUBMITTED ON A TIMELY BASIS, A LATE EMPLOYER LIABILITY MAY BE ASSESSED.
ENROLLMENT APPLICATION INSTRUCTIONS
(This application to be completed by enrolling employer)
APPLICANT INFORMATION
1.Name — Enter applicant's full name (last, first, and middle initial; no nicknames). If applicant has a previous membership under a maiden or other name, enter that name in the space provided.
2.Address — Enter applicant's current mailing address.
3.Social Security Number — Enter applicant’s Social Security number.
4.Gender — Indicate applicant's gender.
5.Date of Birth — Enter applicant's date of birth. Proof of age is required at the time of retirement - if available, attach a photocopy of the applicant's proof of age to this application. Do not delay submitting the Enrollment Application if proof of age is not available. (Acceptable proof of age documents include: birth certificate; passport; naturalization or immigration papers; or certain other records, including baptismal records, military records, census records, school or business records, age recorded on marriage licenses, and insurance or children's birth records.)
6.Daytime Phone Number — Enter applicant's daytime phone number and extension (be sure to include the area code).
7.Is the applicant receiving retirement benefits — Indicate if the applicant is receiving a benefit from a New Jersey
EMPLOYER INFORMATION
8.Employer Name — Enter the full employer name.
9.County — Enter county in which the employer resides.
10.Location, Bureau, and Payroll Numbers — Enter the appropriate location, bureau or payroll number, as applicable. This information should be as reported on your quarterly Report of Contributions (ROC).
11.Title/Position of Applicant — Enter title/position of applicant.
12.Multiple Public Employers — Indicate whether this applicant is employed by more than one public employer. If you answer "Yes", please indicate the full name of each employer.
TPAF APPLICANTS ONLY
13.(a.) Date Employment Began — Enter the date on which applicant started employment. Do not include temporary or substitute service.
(b.) New Jersey Certificate Required — Indicate whether the title/position requires a New Jersey State Certificate issued by the State Board of Examiners within the NJ Department of Education.
(c.) Applicant has New Jersey Certificate — Indicate whether the applicant holds a New Jersey Certificate issued by the State Board of Examiners within the NJ Department of Education.
(d.) Unclassified Professional — For positions with the NJ Department of Education, indicate if the position is "Unclassified Professional".
PERS APPLICANTS ONLY
14. (a.) Date Employment Began — Enter the date on which applicant started employment.
(b.) Permanent Appointment Date — Enter the date of the applicant's regular or permanent appointment.
(c.) Temporary or Provisional — Indicate if the applicant is still considered a temporary or provisional employee.
15.Elected Official – indicate whether the applicant is an elected official. On or after July 1, 2007, a newly elected official is ineligible for enrollment in the PERS. (See Fact Sheet #80.)
16.Appointed Official – Indicate whether the applicant is appointed. State appointees are individuals appointed by the Governor, including those requir- ing the advice and consent of the Senate. Local appointees are individuals appointed by the Governor, including those requiring the advice and con- sent of the Senate or individuals appointed in a similar manner by the governing body of a local entity (county, municipality, etc.). On or after 7/1/07, a newly appointed official who does not have an existing PERS account is ineligible for enrollment in the PERS. (See Fact Sheet #80.)
17.Professional Services Contract – Indicate whether the individual is working under a professional services contract or providing professional serv- ices without benefit of a contract.
18.Base Salary — Enter the annual base salary for the year, that is, the annual salary paid to the employee on the date the Enrollment Application is certified by the employer. Base salary is the contractual salary of the employee. Base salary should not include bonuses, overtime pay, stipends or longevity pay, or sick or vacation time paid in lump sum. Hourly or per diem rates should not be entered.
19.
20.Hours Worked – Indicate whether the applicant works the requisite number of hours. To be eligible for TPAF or PERS membership, the hours worked by an employee enrolled after May 21, 2010, must be fixed at 35 hours or more per week for State employees to be enrolled in the PERS; 32 hours or more per week for Local Government employees to be enrolled in the PERS; or 32 hours or more per week for State or Local Education employ- ees to be enrolled in the TPAF.
EMPLOYER CERTIFICATION
21.Name of Person Completing Application — Print the name of the human resources representative who completes this Enrollment Application for the applicant.
22.Phone Number — Enter employer telephone number for the person who completed this application (be sure to include the area code and exten- sion).
23.Certifying Officer — The Certifying Officer should print his/her name, then sign and date this application. Unsigned applications will be returned.
Please Note: The newly enrolled member’s estate will automatically be designated as the beneficiary for any death benefit payable. New members should register with the Member Benefits Online System (MBOS) to update their beneficiary information online — or submit a paper Designation of Beneficiary form.