Fill and Sign the Student Employee Timesheet Concordia University Chicago Cuchicago Form

The State of New Jersey — Department of the Treasury CV-0636-0803q Division of Pensions and Benefits Application for Volunteer Emergency-Worker's Survivors Pension (VESP) INSTRUCTIONS Part I and Part II are to be completed by the designated representative of the municipality. Include names of dependent children even if spouse is living. See reverse side for eligibility criteria and definitions of a dependent. Part III must be completed and signed by the municipality’s Certifying Officer. PART I — VOLUNTEER WORKER INFORMATION Volunteer's Name:__________________________________________________________________________________ LAST FIRST MI Social Security Number:_________________________ Date of Birth:____/____/_____ Date of Death:_____/____/_____ MM DD YYYY MM DD YYYY Volunteer Title/Position:______________________________________________________________________________ Name of Volunteer Company or Squad:_________________________________________________________________ PART II — SURVIVOR INFORMATION Name of Spouse:___________________________________________________________________________________ LAST FIRST MI Social Security Number:_________________________________ Date of Birth:_____/_____/_____ MM DD YYYY Address:_____________________________________________________ Phone: (______) ______________________ AREA CODE _____________________________________________________ CITY STATE ZIP Dependent Children (Must be disabled or under age 24) 1. Child’s Name:_________________________________________________________ In School? LAST FIRST Yes Social Security Number:_____________________________________ Date of Birth:_____/_____/_____ MM DD YYYY 2. Child’s Name:_________________________________________________________ In School? Yes LAST FIRST No MI Social Security Number:_____________________________________ Date of Birth:_____/_____/_____ MM DD YYYY 3. Child’s Name:_________________________________________________________ In School? Yes LAST No MI FIRST No MI Social Security Number:_____________________________________ Date of Birth:_____/_____/_____ MM DD YYYY (Attach separate sheet to list additional children) Dependent Parents (If no dependent spouse or children) 1. Parent’s Name:_____________________________________________________________________________ LAST FIRST Social Security Number:_____________________________________ MI Date of Birth:_____/_____/_____ MM DD YYYY 1. Parent’s Name:_____________________________________________________________________________ LAST FIRST Social Security Number:_____________________________________ MI Date of Birth:_____/_____/_____ MM (Continued on other side) DD YYYY CV-0636-0803q PART III — CERTIFICATION OF MUNICIPALITY (See “Special Instructions” below) Name of Municipality:___________________________________________ PERS Location Number:________________ Certifying Officer:_____________________________________________ Phone: (_____)________________________ AREA CODE Signature:___________________________________________________ Date:______/______/_______ MM DD YYYY SPECIAL INSTRUCTIONS TO EMPLOYERS If your municipality has had a volunteer emergency-worker die while performing volunteer duties since January 1, 2000, and that volunteer has one or more survivors meeting the criteria of Chapter 134, P.L. 2002 described below, you should: 1. Confirm the eligibility of the survivor(s) for a VESP and have the municipal governing body adopt a resolution certifying to that eligibility. 2. Have this Application for Volunteer Emergency-Worker's Survivors Pension completed and certified. 3. The Division of Pensions and Benefits also requires that the municipality forward the documentation required to certify the eligibility for VESP benefits. This would include: a) the police and/or accident report and the death certificate — required in all cases; b) the marriage certificate — required if there is a surviving spouse; c) birth certificates — required for all dependent children; d) school enrollment records for dependent children over 18 — only required if there is no surviving spouse; e) evidence of disability for dependent children — only required if there is no surviving spouse; f) 4. financial evidence of dependency for dependent parent(s) — only required if there is no surviving spouse or dependent children. Forward the resolution, this completed application, and the documents identified in item 3, above, to the Division within ten days of the resolution’s adoption to: VESP, Division of Pensions and Benefits, PO Box 295, Trenton, NJ 08625-0295. NOTE: Do not delay the submission of the resolution if this application or the collection of other required documentation has not been completed when the resolution is due at the Division of Pensions and Benefits. ELIGIBILITY FOR VESP BENEFITS Chapter 134, P.L. 2002, establishes a pension for the survivors of certain volunteer emergency workers who die in the performance of volunteer duties on or after January 1, 2000. The volunteer must have been a member of a duly incorporated voluntary fire company, first aid and emergency, or ambulance or rescue squad. Survivors (dependents) of a volunteer firefighter, first aid worker, rescue squad worker, or emergency medical technician include: — A widow or widower (who has not subsequently remarried); — Unmarried children (a) under the age of 18; (b) age 18 years of age or older while enrolled in a secondary school; (c) under the age of 24 and enrolled in a degree program at an institution of higher education for at least 12 credit hours each semester; or (d) a disabled child at any age who is incapable of self-support due to the disability; — Dependent parents (if there is no widow, widower, or eligible dependent children) who received at least half of their support from the emergency worker during the twelve months preceding the death. NOTE: If a survivor is also eligible for a monthly pension benefit due to the voluntary emergency worker's membership in a New Jersey State-administered retirement system on the basis of other employment, that survivor is not also eligible for the VESP.