TIER I, TIER II HAZARDOUS DUTY & TIER IIA MEMBERS ONLY
REQUEST FOR EXPLANATION OF RETIREMENT CONTRIBUTION ACCOUNT BALANCE
(Please type or print)
EMPLOYEE NAME:
EMPLOYEE NUMBER:
SOCIAL SECURITY NUMBER:
| EMPLOYEE ADDRESS: | Street: |
| Town: | |
| State, Zip Code: |
SPECIFIC REASON FOR REQUEST:
| _______________________________ | ________________ |
| Employee Signature | Date |
| _______________________________ | ________________ |
| Authorized Agency Signature | Date |
| SEND TO: | RETIREMENT & BENEFIT SERVICES DIVISION |
| OFFICE OF THE STATE COMPTROLLER | |
| 55 ELM STREET | |
| HARTFORD, CT 06106 | |
| ATTN: DATA BASE UNIT |
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