State of Connecticut

Employee Name: Employee Number:
Effective Date of Retirement:

APPLICANT CERTIFICATION

  1. It is my intention to utilize my accrued leave while my application for disability retirement is pending.
  2. I fully understand that using my leave accruals may have a direct effect on the effective date of my retirement.
  3. I further understand the effective date of my retirement may be adjusted when the Medical Examining Board renders a decision (whether it is a favorable decision or not).
  4. Lastly, I understand the effective date of my retirement will be adjusted to the first of the month following either the exhaustion of my leave accruals or when the Medical Examining Board renders their decision, whichever is earlier.
  5. Under no circumstances may I receive salary and retirement income for the same period of time.
_____________________________ ___________________
Employee Signature Date

AGENCY CERTIFICATION

The above-named employee will be paid for unused accrued leave while his/her disability retirement is pending. The following is our representation of the amount of leave that this individual has accrued as of the last working day of the month prior to his/her application for disability retirement.

Number of sick days or hours: __________________ day/hours

Number of vacation days or hours: _______________ day/hours

Agency Statement:

I certify that the information provided herein is accurate. It is understood that it will be the agency's responsibility to revise the current retirement application to include any leave accruals used in the service credit and the average salary.

____________________________ __________________
Authorized Agency Signature Date
____________________________ __________________
Print Name Phone Number

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