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It is important that you read and understand the contents prior to making any decisions regarding elections to

withdraw 401(a) contributions.

 Alternate Benets Program (ABP)  Dened Contribution Retirement Program (DCRP)

Name __________________________________________________________________________________

Date of Birth ______/______/______ Email address ___________________________________________

Social Security Number ______________________ Member Number _____________________________

 Resigned  Dismissed  Retired Date ______/______/______

RETIREMENT AND CASH DISTRIBUTIONS

A vested member of the ABP or the DCRP becomes eligible to commence distributions at any age upon sev-

erance from employment or retirement. Members may receive benets in the form of an annuity or cash distri-

bution. Annuity benets will be calculated by the Designated Service Provider (DSP) based upon the account

accumulation, life expectancy, and the distribution option selected. Participation in the ABP or DCRP shall ter-

minate and the individual shall be considered retired once he or she has elected to receive a cash distribution

of the value of his or her accounts in a direct payout as a cash distribution, a rollover, or an annuity (or a com-

bination of these distributions.) The member is considered retired and is not eligible to enroll in any New Jersey

State-administered retirement system, nor are they eligible to reenroll in or receive any other benets aorded

under the ABP or DCRP. This includes long-term disability coverage.

ABP Only: Cash distributions to members under the age of 55 are limited to their employee contributions and

accumulations. The remaining employer contributions and earnings are available for distribution upon attaining

age 55.

I hereby acknowledge that I have read and understand my election to withdraw funds from my mandatory 401(a)

account.

__________________________________________________________________ ______/______/______

Signature Date

Please fax completed form to (609) 633-1696

State of New Jersey • Department of the Treasury

DIVISION OF PENSIONS & BENEFITS — DEFINED BENEFIT &

DEFINED CONTRIBUTION BUREAU

P.O. Box 295, Trenton, NJ 08625-0295

ALTERNATE BENEFIT PROGRAM (ABP) &

DEFINED CONTRIBUTION RETIREMENT PROGRAM (DCRP) —

WITHDRAWAL REQUEST ACKNOWLEDGMENT RECEIPT

FP-0952-0823