RETIRED BENEFICIARY VERIFICATION FORM MEMBER

Mailing Address:
Beneficiary Services
PO Box 295
Trenton, NJ 08625-0295
STATE OF NEW JERSEY
CB-0481-1011
DEPARTMENT OF THE TREASURY
DIVISION OF PENSIONS AND BENEFITS
RETIRED BENEFICIARY VERIFICATION FORM
Instructions: Please complete this form and return to the Beneficiary Services Section at the address
shown above.
MEMBER INFORMATION:
Name: _____________________________________
SS #: _____________________________________
Pension Membership #: _______________________
County: ___________________________________
Address: __________________________________
__________________________________________
__________________________________________
BENEFICIARY INFORMATION:
Name: _____________________________________
Your Date of Birth: ___________________________
Address: ___________________________________
Daytime
Phone Number: ____________________________
__________________________________________
__________________________________________
Relationship to member (check one):
________ Spouse or Civil Union Partner
__________ Former Spouse or Civil Union Partner
__________ Other
Was member ever Divorced
Yes
No
(If Yes you must submit copies of the Divorce
Decree(s) with Property Settlement(s) and/or QDRO)
Certification Instructions
You must cross out item 2 below if you have been notified by the IRS that you are currently subject to backup withholding
because of underreporting interest or dividends on your tax return. The IRS does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.
Tax Identification Number/Form W9 Certification
Under penalties of perjury, I certify that (1) the number provided below is my correct social security number or taxpayer
identification number, and (2) that I am not subject to backup withholding because (a) I have not been notified that I am
subject to backup withholding as a result of a failure to report interest or dividends, or (b) the Internal Revenue Service has
notified me that I am no longer subject to backup withholding.
By signing below, you are validating the above information is accurate and that you have read and acknowledge
receipt of disclosures regarding your settlement options, as well as the fraud warnings included as part of this for
(see reverse side for fraud warning information).
_____________________________________
Signature
___________________________ __________________
Your Social Security Number or
Taxpayer Identification Number
Date
CALIFORNIA RESIDENTS – For your protection, California law requires the following to appear on this form.
Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and
may be subject to fines and confinement in state prison.
DISTRICT OF COLUMBIA RESIDENTS – Any person who knowingly presents a false or fraudulent claim for
payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of
a crime and may be subject to fines and confinement in prison.
FLORIDA RESIDENTS – Any person knowingly and with intent to injure, defraud, or deceive any insurer files
a statement of claim or an application containing false, incomplete, or misleading information is guilty of a felony
of the third degree.
KENTUCKY RESIDENTS – Any person who knowingly and with intent to defraud any insurance company or
other person files a statement of claim containing any materially false information or conceals, for the purpose
of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a
crime.
NEW JERSEY RESIDENTS – Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.
NEW YORK RESIDENTS – Any person who knowingly and with intent to defraud any insurance company or
other person files an application for insurance or statement of claim containing any materially false information,
or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
PENNSYLVANIA AND UTAH RESIDENTS – Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any material fact thereto
commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
VERMONT RESIDENTS – Any person who knowingly presents a false or fraudulent claim for payment of a loss
or knowingly makes a false statement in an application for insurance may be guilty of a criminal offense under
state law.
VIRGINIA RESIDENTS – Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or other person, or knowing that he is facilitating commission of a fraud, submits incomplete,
false, fraudulent, deceptive or misleading facts or information when filing a statement of claim for payment of a
loss or benefit may have violated state law, is guilty of a crime and may be prosecuted and punished under state
law. Penalties may include fines, civil damages and criminal penalties, including confinement in prison. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by
the applicant or if the applicant conceals, for the purpose of misleading, information concerning any fact material thereto.
WASHINGTON RESIDENTS – Any person who knowingly provides false, incomplete, or misleading information
to an insurance company for the purpose of defrauding the company commits a crime. Penalties include imprisonment, fines, and denial of insurance benefits.
For residents of all states except California, the District of Columbia, Florida, Kentucky, New Jersey, New
York, Pennsylvania, Utah, Vermont, Virginia and Washington;
WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or
other person, or knowing that he is facilitating commission of a fraud, submits incomplete, false, fraudulent,
deceptive or misleading facts or information when filing an insurance application or a statement of claim for payment of a loss or benefit commits a fraudulent insurance act, is/may be guilty of a crime and may be prosecuted and punished under state law. Penalties may include fines, civil damages and criminal penalties, including
confinement in prison. In addition, an insurer may deny insurance benefits if false information materially related
to a claim was provided by the applicant or if the applicant conceals, for the purpose of misleading, information
concerning any fact material thereto.