WAIVER OF RETIREMENT PLAN PARTICIPATION
Connecticut State University Part-time Employees

Rev. 3-1-08

Part-time employees covered by the collective bargaining agreement between the State and the Connecticut State University - American Association of University Professors, Inc. (CSU-AAUP/BOT) contract must participate in a retirement plan unless they irrevocably waive retirement plan membership for this and any subsequent part-time employment with the agency named below or with the Board of Governors of Higher Education or any other of its constituent units. If you are covered by this contract and wish to irrevocably waive your right to join a pension plan, please complete the following:

_______________________________ _________________ ____________________
Employee Name (Type or Print) Employee Number Social Security Number


_______________________________ _________________ ____________________
Agency Name Date of Employment Bargaining Unit


EMPLOYEE'S STATEMENT: I hereby irrevocably waive my right to membership in a retirement plan for this and any subsequent part-time employment with this agency or the Board of Governors of Higher Education or any other of its constituent units within the State of Connecticut.

_______________________________________ ___________________
Employee's Signature Date


_______________________________________ ___________________ _____________
Authorized Agency Signature, Title Date Phone Number


Forward original to:

Office of the State Comptroller
Retirement & Benefit Services Division
Data Base Unit
55 Elm Street, Hartford, CT 06016.

Copies to agency and employee.

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