Form Fl-0781-0511 Nj Dcrp Enrollment Application (Page 2 of 2) in pdf

FL-0781-0511

ENROLLMENT APPLICATION INSTRUCTIONS

FOR ELECTED OR APPOINTED OFFICIALS

(This application to be completed by the enrolling employer)

APPLICANT INFORMATION

1. Name — Enter applicant's full name (first, middle initial, and last name).

2. Social Security Number — Enter applicant’s Social Security number.

3. 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.)

4. Gender — Indicate applicant's gender.

5. Daytime Phone Number — Enter applicant's daytime phone number and extension (be sure to include the area code).

6. Address — Enter applicant's current mailing address.

7. Is the applicant receiving retirement benefits — Indicate if the applicant is receiving a benefit from a New Jersey

State-administered retirement system or local New Jersey retirement system, and give the system's name.

EMPLOYER INFORMATION

8. Employer Name — Enter the full employer name.

9. County — Enter county in which the employer is located.

10. Location and Payroll Numbers — Enter the appropriate location or payroll number, as applicable.

11. Date Elected or Appointed Service Commenced — Enter the date on which applicant began service in the elected

or appointed position.

12. Current Annual Base Salary — Enter the annual base salary for the year, that is, the annual salary paid to the elect-

ed or appointed official on the date the Enrollment Application is certified by the employer. Base salary is the contrac-

tual salary of the official. 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.

13. Title/Position of Applicant — Enter official title/position of applicant.

14. Elected Official — Indicate if the applicant is an Elected Official of the State of New Jersey or of a political subdivision

thereof.

15. Appointed Position — Indicate if the applicant is appointed by Special Resolution or Ordinance or by the Governor of

New Jersey, as described in N.J.S.A. 43:15C-2.

EMPLOYER CERTIFICATION

16. Phone Number — Enter employer telephone number for the person who completed this application (be sure to include

the area code and extension).

17. Signature — The Certifying Officer and the Certifying Officer’s Supervisor must sign and date this application.

Unsigned applications will be returned.

BENEFICIARY DESIGNATION

The newly enrolled member’s estate will automatically be designated as the beneficiary for any death benefit payable. New

members who wish to name a specific beneficiary should submit a Designation of Beneficiary using the Member Benefits

Online System (MBOS) — go to for details; or submit a Designation

of Beneficiary form to the Division of Pensions and Benefits.

Form Fl-0781-0511 Nj Dcrp Enrollment Application Page 2