MAIL TO:
DIVISION OF EMPLOYER ACCOUNTS, WORKER REFUND UNIT "2017", PO BOX 910, TRENTON, NEW JERSEY 08625-0910
SOCIAL SECURITY NUMBER
EMPLOYEE'S NAME
STREET ADDRESS
CITY, STATE AND ZIP CODE
UC-9A (R-01-01-19)
State of New Jersey
Department of Labor and Workforce Development
DIVISION OF EMPLOYER ACCOUNTS
EMPLOYEE'S CLAIM FOR REFUND
OF EXCESS CONTRIBUTIONS
FOR THE CALENDAR YEAR 2018
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 $128.90 for New Jersey Unemployment Insurance, in excess of $30.33 for Family Leave
Insurance, in excess of $14.32 for New Jersey Workforce Development Partnership Fund and in excess of $64.03 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 New Jersey Unemployment Insurance, Family Leave Insurance, 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.
Signature
Date
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
FOR INTERNAL USE ONLY
W.F. Refund
D. I. Refund
F.L.I. Refund
U.I. Refund
Total Refund
Telephone No.
INSTRUCTIONS FOR COMPLETING UC-9A AND OBTAINING EMPLOYER
CERTIFICATIONS
COMPLETING UC-9A REFUND FORM
1. TYPE or PRINT* your Social Security Number and your exact name an
d address at the top of the claim.
2. SIGN and DATE the refund claim.
3. TYPE or PRINT the exact name and location of all your employers who made deductions for New Jersey Family
Leave Insurance, Workforce Development Partnership Fund, Unemployment and Disabiliy Insurance from your
2017 wages and state the total amount of wages from which the deductions were made.
*LEGIBLE INFORMATION WILL ENSURE PROPER REIMBURSEMENT
OBTAINING CERTIFICATIONS
Your ref und claim must also be accompanied by a certification of the deductions made by each of your employers listed on your
claim.
Certification of your wages and deductions can be obtained through one
of the following:
Have your employer complete form UC- 52, "Employer Certification of Wages and Deductions for New Jersey
Workforce Development Partne
rship Fund, Unemployment, Temporary Disability Insurance and Family Leave Insurance."
1.
OR
2.
Furnish a copy of your W-2 Tax Statement provided
the form shows the amounts withheld as worker contributions
for New Jersey Family Leave Insurance, Workf orce Development Partnership Fund, Unemployment and Disability
Insurance.
Mail the completed original UC-9A form together with ALL of your employer certifications to the Division of Employer Accounts,
Worker Refund Unit "2018", P. O. Box 910, Trenton, New Jersey 08625-0910.
After your claim has been received it will be audited and verified. However, no refunds will be issued prior to August 31, 2019, as
claims must be cross-matched wit h Gross In come Tax records to avoid the possibility of issuing duplicate credits and/or refunds.
Please allow 6-8 weeks for processing time.
If you have any questions concerning your claim you may write to the above address or call (609) 633-6400. In communicating with
this Agency concerning your claim, be sure to refer to your Social Security Number.
NOTE: IF THE AMOUNT DEDUCTED BY ANY ON E EMPLOYER EXCEEDS THE M AXIMUM FOR EITHER NEW JERSEY
FAMILY LEAVE INSURANCE, WORKFORCE DEVELOPMENT PARTNERSHIP FUND, UNEMPLOYMENT OR
DISABILITY INSURANCE, YOU SHOULD CONTACT THAT EMPLOYER FOR A REFUND OF THE BALANCE OF THE
DEDUCTION.
