State of Connecticut

Attachment to MEMORANDUM NO. 2003-24

DEFERRED PAYMENT OF ACCRUED VACATION AND SICK LEAVE FOR PARTICIPANTS OF THE 2003 EARLY RETIREMENT INCENTIVE PROGRAM
 
ONE COPY OF THIS FORM SHOULD BE DELIVERED TO EACH OF THE FOLLOWING : THE STATE COMPTROLLER PAYROLL SERVICES DIVISION, 55 ELM STREET, HARTFORD, CONNECTICUT, 06106, THE STATE COMPTROLLER RETIREMENT AND BENEFITS SERVICES DIVISION, 55 ELM STREET, HARTFORD, CONNECTICUT, 06106, AND RETAINED AT THE AGENCY.
AGENCY NAME DEPARTMENT PAGE OF
FUND SOURCE
FUND/AGENCY/SID*
EMPLOYEE NAME EMPLOYEE NUMBER EMPLOYEE SOC. SEC.
NUMBER
AMOUNT OF ACCRUAL INSTALLMENT
INSTALLMENT DATE 7/1/2005 7/1/2006 7/1/2007
        CHECK DATE 6/24/2005 6/23/2006 6/22/2007
Total Vacation
Due
$           /3
     
Total Sick
Due
$           /3
     
        Total Vacation
Due
$         /3
     
Total Sick
Due
$          /3
     
        Total Vacation
Due
$           /3
     
Total Sick
Due
$           /3
     
       
 
CERTIFICATION OF AGENCY REPRESENTATIVE
* INDICATE ANY ANTICIPATED FUNDING PROBLEMS ON AN ATTACHED PAGE

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