Name(s) as shown on Form NJ-1040                                                                                         Social Security Number

                                     Employee’s Claim for Credit For Excess UI/WF/SWF,  
   Form NJ-2450                      Disability Insurance, and/or Family Leave                                           2021
                                     Insurance Contributions for Calendar Year 2021
To claim this credit, you must complete the items below using the information from your W-2 forms. Enclose this form and the W-2s 
with your New Jersey State Income Tax return. Any items not substantiated by a W-2 or any information that is incomplete will 
cause the claim to be rejected. The amount withheld for unemployment insurance/workforce development partnership fund/supple-
mental workforce fund, disability insurance, and family leave insurance must be reported separately on all W-2 statements.
Note on Joint NJ-1040 return: Each spouse/CU partner must file a separate Form NJ-2450 when claiming a refund for excess 
contributions.
   Claimant Name:                                                            Claimant SSN:
   Address: 
   City:                                                State:                     ZIP Code: 
Take All Information From Your W-2 Forms.                                         Column A       Column B                      Column C
If the amount deducted by any one employer exceeds the maximum 
for either UI/WF/SWF, disability insurance, or family leave insurance,            UI/WF/SWF      Disability              Family Leave
enter the maximum in the appropriate column(s) and contact that                   Deducted       Insurance                     Insurance
employer for a refund of the balance of the deduction.                                           Deducted                      Deducted
1A. Employer’s Name:
   Fed. Emp. I.D.#:
   Private Plan#:                               Wages:
B. Employer’s Name:
   Fed. Emp. I.D.#:
   Private Plan#:                               Wages:
C. Employer’s Name:
   Fed. Emp. I.D.#:
   Private Plan#:                               Wages:
D. Employer’s Name:
   Fed. Emp. I.D.#:
   Private Plan#:                               Wages:
E. Employer’s Name:
   Fed. Emp. I.D.#:
   Private Plan#:                               Wages:
F. *If additional space is required, enclose a rider and enter the 
   total on this line. 
2. Total Deducted. Add lines 1A through 1F. Enter here.
3. Correct UI/WF/SWF, Disability Insurance, and/or Family Leave 
   Deductions.                                                                    153.85         649.54                        386.96
4. Subtract line 3 column A from line 2 column A. Enter on line 58 
   of the NJ-1040.
5. Subtract line 3 column B from line 2 column B. Enter on line 59 
   of the NJ-1040.
6. Subtract line 3 column C from line 2 column C. Enter on line 60 
   of the NJ-1040.
I hereby apply for a credit for worker contributions deducted in excess of $153.85 for NJ UI/WF/SWF and/or in excess of $649.54 for NJ Disability 
Insurance and/or in excess of $386.96 for NJ Family Leave Insurance deductions by reason of having received wages from two or more employers 
during the above calendar year and hereby submit the following statement of wages and deductions.
Claimant’s Signature:                                                                              Date:  

Instructions for obtaining a credit for excess 
UI/WF/SWF, Disability Insurance, and/or Family 
Leave Insurance Contributions

To  claim  the  credit,  you  must  enclose  Form  NJ-2450  with  your  NJ-1040 
return.  If  this  form  is  not  enclosed  with  the  NJ-1040,  or  if  the  required  
information from the W-2 forms is not available to substantiate the claim, the 
credit will be denied. The law prohibits the processing of claims submitted later 
than two years after the calendar year in which wages were paid.

If a joint NJ-1040 return is filed and both spouses/CU partners have excess con-
tributions withheld by two or more employers, each spouse/CU partner must file 
his or her own claim form along with the NJ-1040 return.

If  any  single  employer  withholds  more  than  the  maximum  for  either  UI/
WF/SWF,  disability  insurance,  and/or  family  leave  insurance  contributions, 
enter only the maximum on the claim form. Any amounts over the maximum were 
withheld in error and must be refunded by that particular employer. Refunds of 
overwithholdings of contributions by an individual employer are the responsibility 
of that employer and cannot be claimed as a credit on your Income Tax return.

If  additional  space  is  required  due  to  the  number  of  employers,  enclose 
a  list  with  the  required  information  as  on  the  NJ-2450  form.  If  this  list  is  
incomplete or is not enclosed with the claim, the credit will be denied.

After  lines  1A  through  1F  are  completed,  complete  all  necessary  calculations 
from lines 2 through 6. Carry the amounts on line 4, 5, and/or 6 to the specified 
lines on the NJ-1040 return.

If  you  are  notified  that  your  claim  has  been  denied  by  the  Division  of  
Taxation  for  any  reason,  you  must  refile  your  claim  for  refund  of  excess  UI/
WF/SWF,  disability  insurance,  or  family  leave  insurance  contributions  with 
the  Department  of  Labor  and  Workforce  Development  on  Form  UC-9A,  
“Employees  Claim  for  Refund  of  Excess  Contributions.”  Once  your  claim  has 
been denied by the Division of Taxation, it cannot be reinstated.