State of Connecticut

Attachment "H" 

Name:
Employee No.:
Date of Retirement:

STATE EMPLOYEES RETIREMENT COMMISSION
PROOF OF BIRTH
AFFIDAVIT

STATE OF CONNECTICUT )
)ss
COUNTY OF )

 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.

 

____________________________
Signature

Subscribed and sworn to
before me this_______
day of 20___ .

 

_________________________________
Notary Public
Commissioner of the Superior Court 

PLEASE NOTE

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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