Form EE-0904-0814 "Notification of Employment After Retirement" - New Jersey

What Is Form EE-0904-0814?

This is a legal form that was released by the New Jersey Department of the Treasury - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

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Download a printable version of Form EE-0904-0814 by clicking the link below or browse more documents and templates provided by the New Jersey Department of the Treasury.

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Download Form EE-0904-0814 "Notification of Employment After Retirement" - New Jersey

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EE-0904-0814
STATE OF NEW JERSEY
DIVISION OF PENSIONS AND BENEFITS
NOTIFICATION OF EMPLOYMENT AFTER RETIREMENT
DO NOT WRITE IN THIS BOX
LOCATION NO.
MEMBERSHIP NO.
THIS FORM IS TO BE COMPLETED BY THE EMPLOYER AND TO BE USED WHEN HIRING ANYONE WHO IS COLLECTING A
-
.
RETIREMENT BENEFIT FROM ANY NJ STATE
ADMINISTERED RETIREMENT SYSTEM
EMPLOYEE INFORMATION:
(Please print and follow the instructions on page 2 of this form.)
1. Name: _______________________________________________________________________________________
Last
First (no nicknames)
Middle
2. Address:___________________________________________________________________________________________________________________________
Street
City
State
Zip Code
3b. Retirement Type: ¨ Disability ¨ Other
3a. Retirement # or Former Membership #: ________________
4. Gender: ¨ Male ¨ Female
5. Date of Birth: _____/_____/_____
6. Daytime Phone: ( _____ ) ______ - _____________
Month
Day
Year
7a. Indicate employee’s date of retirement: _____/_____/_____
7b. Employer at Retirement : _________________
Month
Day
Year
EMPLOYMENT AFTER RETIREMENT INFORMATION
8. Employer Name: ________________________________________________________________________________
9. County: ______________________ 10. Location #: ____________ Bureau #: ___________ Payroll #: ___________
If Applicable
State Only
11. Title/position currently held by employee: ____________________________________________________________
¨ Annual Salary $____________
¨ Hourly wages: $____________
12. Indicate the employee’s earnings (
check one) :
¨ Full time
¨ Part-time
13. Describe the type of service:
If part-time, indicate hours pers week: ____________
14a. Date employment began: ____/____/____ 14b. Date employment is expected to end, if known: ____/_____/____
Month
Day
Year
Month
Day
Year
EMPLOYER CERTIFICATION
15. If the applicant retired from your location, did he/she complete a 180-day “bona fide severance of employment?”
¨ Yes ¨ No (If the applicant did not retire from your location, leave blank and continue to Item 16.)
Was there an agreement regarding employment after retirement for any position, paid or volunteer, at or about the
16.
¨ Yes ¨ No If yes, indicate date if known: _____/_____/_____
time of the employee’s retirement?
Month
Day
Year
I certify that the above information is accurate. I acknowledge that I am subject to penalty for falsifying or permitting to be falsified
any record, application, form, or report of the retirement system in an attempt to defraud the system pursuant to N.J.S.A. 43:3C-15
(Two Signatures Required).
17. ____________________________________________________________________ Date: ______/______/_____
Signature of Certifying Officer
Month
Day
Year
18. ____________________________________________________________________ Date: ______/______/______
Signature of Certifying Officer’s Supervisor
Month
Day
Year
19. Phone Number of Certifying Officer: ( _____ ) _______ - _____________ Ext.: ____________
NOTE: THIS NOTIFICATION MUST BE SUBMITTED WITHIN 15 CALENDAR DAYS OF EMPLOYMENT TO
THE ATTENTION OF THE EXTERNAL AUDIT UNIT,
DIVISION OF PENSIONS AND BENEFITS, PO BOX 295, TRENTON, NJ 08625-0295
EE-0904-0814
STATE OF NEW JERSEY
DIVISION OF PENSIONS AND BENEFITS
NOTIFICATION OF EMPLOYMENT AFTER RETIREMENT
DO NOT WRITE IN THIS BOX
LOCATION NO.
MEMBERSHIP NO.
THIS FORM IS TO BE COMPLETED BY THE EMPLOYER AND TO BE USED WHEN HIRING ANYONE WHO IS COLLECTING A
-
.
RETIREMENT BENEFIT FROM ANY NJ STATE
ADMINISTERED RETIREMENT SYSTEM
EMPLOYEE INFORMATION:
(Please print and follow the instructions on page 2 of this form.)
1. Name: _______________________________________________________________________________________
Last
First (no nicknames)
Middle
2. Address:___________________________________________________________________________________________________________________________
Street
City
State
Zip Code
3b. Retirement Type: ¨ Disability ¨ Other
3a. Retirement # or Former Membership #: ________________
4. Gender: ¨ Male ¨ Female
5. Date of Birth: _____/_____/_____
6. Daytime Phone: ( _____ ) ______ - _____________
Month
Day
Year
7a. Indicate employee’s date of retirement: _____/_____/_____
7b. Employer at Retirement : _________________
Month
Day
Year
EMPLOYMENT AFTER RETIREMENT INFORMATION
8. Employer Name: ________________________________________________________________________________
9. County: ______________________ 10. Location #: ____________ Bureau #: ___________ Payroll #: ___________
If Applicable
State Only
11. Title/position currently held by employee: ____________________________________________________________
¨ Annual Salary $____________
¨ Hourly wages: $____________
12. Indicate the employee’s earnings (
check one) :
¨ Full time
¨ Part-time
13. Describe the type of service:
If part-time, indicate hours pers week: ____________
14a. Date employment began: ____/____/____ 14b. Date employment is expected to end, if known: ____/_____/____
Month
Day
Year
Month
Day
Year
EMPLOYER CERTIFICATION
15. If the applicant retired from your location, did he/she complete a 180-day “bona fide severance of employment?”
¨ Yes ¨ No (If the applicant did not retire from your location, leave blank and continue to Item 16.)
Was there an agreement regarding employment after retirement for any position, paid or volunteer, at or about the
16.
¨ Yes ¨ No If yes, indicate date if known: _____/_____/_____
time of the employee’s retirement?
Month
Day
Year
I certify that the above information is accurate. I acknowledge that I am subject to penalty for falsifying or permitting to be falsified
any record, application, form, or report of the retirement system in an attempt to defraud the system pursuant to N.J.S.A. 43:3C-15
(Two Signatures Required).
17. ____________________________________________________________________ Date: ______/______/_____
Signature of Certifying Officer
Month
Day
Year
18. ____________________________________________________________________ Date: ______/______/______
Signature of Certifying Officer’s Supervisor
Month
Day
Year
19. Phone Number of Certifying Officer: ( _____ ) _______ - _____________ Ext.: ____________
NOTE: THIS NOTIFICATION MUST BE SUBMITTED WITHIN 15 CALENDAR DAYS OF EMPLOYMENT TO
THE ATTENTION OF THE EXTERNAL AUDIT UNIT,
DIVISION OF PENSIONS AND BENEFITS, PO BOX 295, TRENTON, NJ 08625-0295
EE-0904-0814
INSTRUCTIONS
THIS FORM IS TO BE COMPLETED BY THE EMPLOYER AND TO BE USED WHEN HIRING ANYONE WHO IS COLLECTING A
-
.
RETIREMENT BENEFIT FROM ANY NJ STATE
ADMINISTERED RETIREMENT SYSTEM
EMPLOYEE INFORMATION
1.
Name — Enter employee’s full name (last, first, and middle initial; no nicknames).
2.
Address — Enter employee’s current mailing address.
3a. Retirement or Former Membership Number — Enter either number.
3b. Type of Retirement — Indicate whether the employee retired under a disability retirement or other type of retirement (Service,
Early, etc.)
4.
Gender — Indicate employee’s gender.
5.
Date of Birth — Enter employee’s date of birth. Proof of age should be on file since it is a condition of retirement.
6.
Daytime Phone Number — Enter employee’s daytime phone number and extension (be sure to include the area code).
7a. Indicate employee’s date of retirement — Indicate when the employee began receiving a benefit from a New Jersey State-
administered retirement system.
7b. Employer at Retirement — Indicate location from which employee initially retired.
EMPLOYMENT AFTER RETIREMENT INFORMATION
8.
Employer Name — Enter the full employer name.
9.
County — Enter county in which the employer is located.
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) or to Centralized Payroll for State loca-
tions.
11. Title/Position currently held by employee — Enter current title/position for the employee. Also indicate whether the employ-
ee is performing services as an employee or as an independent contractor. A job description can be submitted with the form,
if available.
12. Indicate the employee’s earnings — Indicate whether the employee earns an annual salary or hourly wage and specify the
amount.
13. Describe the type of service being provided — Indicate the capacity (part-time or full-time) in which this employee is
employed and if part-time, specify how many hours per week.
14a. Date Employment Began — Enter the date on which employee started employment at your location.
14b. Date Employment is Expected to End — Enter the date on which employment will end, if applicable or known.
EMPLOYER CERTIFICATION
15. Bona Fide Severance from Employment — If the applicant retired from your location, indicate whether the employee has
completed at least a 180-day break in service pursuant to N.J.A.C. 17:1-17.14. If the applicant did not retire from your location,
leave Item 15 blank and continue to Item 16.
16. Preplanning or Prearranged Agreement — Indicate if, at or about the time of the employee’s retirement, there were dis-
cussions or an agreement regarding employment (in any paid or voluntary basis) after the employee’s retirement.
17. Certifying Officer — The Certifying Officer must sign and date this form. Unsigned forms will be returned.
18. Certifying Officer’s Supervisor — The Certifying Officer’s Supervisor must sign and date this form. Unsigned forms will
be returned.
19. Phone Number — Enter the telephone number for the Certifying Officer who is completing this form (be sure to include the
area code and extension).
IMPORTANT INFORMATION
This notification is required to be completed and returned to the Division within 15 calendar days after the employee’s date of
hire. The employer must also notify the Division when the employee’s services have been terminated. Forms should be
returned to Attn: External Audit Unit, Division of Pensions and Benefits, PO Box 295, Trenton, NJ 08625-0295
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