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Forms Payroll Forms
Affidavit of Dependency: Application for Retirement Allowance: For members of PERS and TPAF to file for retirement. For members of PFRS to file for retirement. The Application for Retirement Allowance must completed and returned to the forwarded to Human Resources. The NJ Division of Pensions & Benefits will not process your retirement application without required certification from the University. Click here for Form and Instructions for PERS and TPAF Members Click here for Form and Instructions for PFRS Members Application for Withdrawal: For members of PERS, TPAF and PFRS who have terminated their employment and wish to withdraw their pension contributions. This form must be returned to the Office of Payroll and Benefits for processing. Click here for Instructions and Form Designation of Beneficiary: For members of PERS, TPAF, PFRS and ABP to nominate beneficiaries for benefits, which may include group life insurance and return of accumulated pension contributions, payable upon the death of the member. You may mail the form directly to the NJ Division of Pensions & Benefits who will then send you a confirmation of the changes. Note to ABP members: Please contact your investment vendor(s) for the appropriate form to amend or elect beneficiaries for return of accumulated pension contributions. Click here for Form and Instructions NJ Prescription Drug Program: For employees enrolled in the NJ Prescription Drug Program to obtain reimbursement for prescriptions obtained from a non-participating pharmacy or when coverage was effective but a prescription I.D. card was not yet received. This form should be mailed directly to the carrier. Click here for Mail Order Form Click here for Prescription Drug Reimbursement Form New Jersey State Dental Expense Plan Claim Form: For participants in the Dental Expense Plan to file a claim for covered expenses or to obtain a pretreatment estimate with Aetna USHC. This form should be mailed directly to the carrier. Click here for Form and Instructions New Jersey State Dental Benefits Application: For eligible full time employees to enroll for the first time, change coverage level (adding/deleting dependents), or terminate coverage in the Dental Plan. Applications must be completed with 60 days of the event. This form is also used during the annual open
enrollment period (the month of October) to change to another dental plan. NJ Plus Claim Form: Purchasing Service Credit: Retirement allowance in PERS, TPAF and PFRS is based, in part, on the amount of service credit posted to the member's pension account. The types of service credit which may be purchased are described and an Application to Purchase Service Credit is provided. This form must then be returned to HR for processing. Click here for Form and Instructions Request for Retirement Estimate: For members of PERS and TPAF - request to receive calculation of monthly retirement income and description of survivor options for members within 2 years of retirement. For members of PFRS - request to receive calculation of monthly retirement income and widows/widower's pension for members within 2 years of retirement. This form may be mailed directly to the NJ Division
of Pensions & Benefits who will mail the information to your home
address. Request for Leave of Absence Without Pay: NJ State Family Leave/Family and Medical Leave Act (FMLA), Specific Notice: A form to request a leave without pay and accompanying information describing your rights and obligations under the family leave acts. Note to unclassified staff (faculty and administrators): please refer to the Faculty and Professional Staff Handbook for information on applying for a paid or unpaid leave of absence. Click here for Form Traditional Plan Claim Form: For participants in the Traditional Plan to file a claim for services or supplies with Horizon Blue Cross and Blue Shield. This form should be mailed directly to the carrier. Click here for Form and Instructions Vision Care Program: Claim form for eligible full time employees to request reimbursement for vision care expenses for themselves and their dependents. The completed form and accompanying receipts are then forwarded to the Payroll Department. Click here for Instructions Click here for Form
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