State of Connecticut

ATTACHMENT B

RETIREMENT CREDIT FOR LAYOFF - PUBLIC ACT NO. 03-2

New 03-01-06

Employee Information

Employee Name: Employee No.:
Address: SS #:

State Employees Retirement System
Retirement Plan Membership:

Lay-Off Information *

Date:
Agency:
Position:
Salary:

Reemployment Information

Date:
Agency:
Position:
Salary:

_______________________________________ _________________
Employee Signature Date

_______________________________________ _________________ __________________
Authorized Agency Signature Date Telephone Number

*Copy of original lay-off notice must be attached.

Return to retirement memo dated 3/27/2006

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