State of Connecticut

ELECTION UNDER THE 2003 EARLY RETIREMENT INCENTIVE PROGRAM AND DEFERRAL OF THE EFFECTIVE DATE OF RETIREMENT: EXCLUSIVELY FOR ELIGIBLE EMPLOYEES SPECIFIED IN SPECIAL ACT NO. 03-2.

STATE OF CONNECTICUT
OFFICE OF THE STATE COMPTROLLER
RETIREMENT & BENEFIT SERVICES DIVISION
55 ELM STREET
HARTFORD, CT 06106-1775
CO-1101A REV 05/03
NAME OF SERS MEMBER (APPLICANT)

EMPLOYEE NUMBER
TITLE OF POSITION

EMPLOYING AGENCY

PART I: RETIREMENT ELECTION
(TO BE COMPLETED BY THE SERS MEMBER)


I HEREBY ELECT AS A MEMBER OF THE STATE EMPLOYEES RETIREMENT SYSTEM TO RETIRE EFFECTIVE NO LATER THAN JUNE 1,2003 UNDER THE 2003 EARLY RETIREMENT INCENTIVE PROGRAM. I UNDERSTAND THAT IF THIS ELECTION FORM IS NOT ON FILE IN THE RETIREMENT & BENEFIT SERVICES DIVISION ON OR BEFORE MAY 30, 2003, I WILL BE INELIGIBLE FOR THE THREE INCENTIVE YEARS OF CREDIT PROVIDED BY THE PROGRAM. IN ADDITION, I UNDERSTAND THAT I MUST MEET THE ELIGIBILITY REQUIREMENTS SET FORTH BY THE PROGRAM BEFORE JUNE 1, 2003.

SIGNATURE OF SERS MEMBER (APPLICANT)

DATE

PART II: DEFERRAL OF EFFECTIVE DATE
(TO BE COMPLETED BY AUTHORIZED AGENCY PERSONNEL)

THE EFFECTIVE DATE OF RETIREMENT FOR THE ABOVE REFERENCED EMPLOYEE, AN EMPLOYEE AT THIS AGENCY, IS BEING DEFERRED TO
_____________________________ IT IS UNDERSTOOD THAT ALL PAPERWORK ASSOCIATED WITH A RETIREMENT
ENTER AN EFFECTIVE DATE OF RETIREMENT 
NO LATER THAN JUNE 1,2004.
APPLICATION UNDER THE EARLY RETIREMENT INCENTIVE PROGRAM MUST BE RECEIVED BY THE RETIREMENT & BENEFIT SERVICES DIVISION PRIOR TO THE MEMBER'S DEFERRED EFFECTIVE DATE OF RETIREMENT.

 

AUTHORIZED AGENCY SIGNATURE
TITLE
DATE

AUTHORITY FOR DEFERRAL AS OUTLINED IN RETIREMENT & BENEFIT SERVICES DIVISION MEMORANDUM DATED MAY 2, 2003 MUST BE ATTACHED TO THIS FORM.

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