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Form Uc-9a - Employee'S Claim For Refund Of Excess Contributions For The Calendar Year 2000

MAIL TO:

DIVISION OF EMPLOYER ACCOUNTS, WORKER REFUND UNIT "99", PO BOX 076, TRENTON, NEW JERSEY 08625-0076

UC-9A (R-2-01)

SOCIAL SECURITY NUMBER:

State of New Jersey

Department of Labor

DIVISION OF EMPLOYER ACCOUNTS

EMPLOYEE'S

NAME:

EMPLOYEE'S CLAIM FOR

STREET

REFUND OF EXCESS CONTRIBUTIONS

ADDRESS:

FOR THE CALENDAR YEAR 2000

CITY, STATE

ZIP CODE:

PLEASE READ THE INSTRUCTIONS CAREFULLY ON THE REVERSE BEFORE COMPLETING THIS CLAIM

STATEMENT OF REFUND CLAIMANT

I hereby apply for a refund of worker contributions in excess of $42.40 for New Jersey Unemployment Insurance, in excess of $42.40 for New Jersey Health

Care Subsidy Fund, in excess of $5.30 for New Jersey Workforce Development Partnership Fund and in excess of $106.00 for New Jersey Disability

Insurance by reason of having received wages from two or more employers during the above calendar year and in support thereof, submit the following

statement of employer certifications of wages and deductions for Unemployment Insurance, New Jersey Health Care Subsidy Fund, Workforce

Development Partnership Fund and Disability Insurance. In addition, I have either been determined ineligible or have not applied for this refund as a credit

toward my New Jersey Gross Income Tax.

Date

Signature

STATEMENT OF EARNINGS

EMPLOYER'S NAME

CITY AND STATE

WAGES

(Use additional sheets, if necessary)

MAKE SURE THAT ALL CERTIFICATIONS ARE ATTACHED BEFORE FILING YOUR CLAIM

W.F. Refund

D. I. Refund

U. I. Refund