Date of Retirement:
STATE EMPLOYEES RETIREMENT COMMISSION
PROOF OF BIRTH
|STATE OF CONNECTICUT||)|
being duly sworn, deposes and says:
1. I am unable to comply with the rule of the State Employees Retirement Commission of the State of Connecticut requiring the filing of a properly attested certificate of my birth.
2. To the best of my knowledge and belief I was born at
_____________________on the ________day of ____________, 19 ___.
3. In lieu of said certificate, I hereby accept and irrevocably establish said date as my correct and legal date of birth for all purposes of the State of Connecticut.
Subscribed and sworn to
before me this_______
day of 20___ .
Commissioner of the Superior Court
In addition to the completed affidavit, you must submit two (2) documents, as described on the instruction sheet provided to you, which support your claim of your exact birthdate.
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