State of Connecticut

Attachment to Retirement Division Memorandum:
2003 Personal Statement of Benefits for Tier I, Tier II and Tier IIA 
Members of the State Employees Retirement System

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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