State of Connecticut

ATTACHMENT

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

Return to retirement memo dated 9/15/2006

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