State of Connecticut

ATTACHMENT TO
RETIREMENT & BENEFIT SERVICES DIVISION MEMORANDUM:

Employer "Pick-Up" of Mandatory Employee Retirement Contributions
dated January 30, 2002

Municipal Employees Retirement System

MEMBER CONTRIBUTION PICK-UP ELECTION FORM

Name of Municipality: __________________________________________________

Name of Municipal Group: ______________________________________________

Town number (three digits): ____________ Group Code (one letter): _____________

The above named municipality hereby elects to pick-up member contributions made to the Municipal Employees Retirement System (MERS) by the municipal group specified above in accordance with Connecticut General Statutes, Section 7-440 and the employer pick-up option provided for in Public Act No. 01-80 effective January 1, 2002.

The effective date of this election must coincide with the first day of a MERS monthly reporting period and it cannot be any earlier than the date the election form is signed. This election is effective for payroll-deducted mandatory contributions required on compensation paid on and after such effective date. These picked-up member contributions shall be paid from the same source of funds as used to pay the member.

The contributions picked-up shall be treated as employer contributions in determining tax treatment under the U.S. Internal Revenue Code. Member contributions picked-up pursuant to this provision shall be treated for all other purposes in the same manner, and to the same extent, as employee contributions made prior to the effective date of this provision. Election of the employer pick-up option is irrevocable.

Date Signed: ______________________ Effective Date: _________________________

Authorized signature: ______________________________________________________

Name (Printed): __________________________________________________________

Title: _________________________________ Telephone Number: _________________

Witness Name (Printed): ___________________________________________________ 

Witness Signature: ________________________________________________________ 

Return completed election form to:
Retirement & Benefit Services Division
Municipal Employees Retirement System
55 Elm Street
Hartford, CT 06106 MERS-1/2002

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