State of Connecticut

Attachment to Retirement Memorandum

OFFICE OF THE STATE COMPTROLLER

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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