WAIVER OF RETIREMENT PLAN PARTICIPATION
University of Connecticut Special Payroll Lecturers
Rev. 3-1-08

Special Payroll Lecturers covered by the May 26, 2005 agreement between the University of Connecticut (UConn) and the American Association of University Professors must participate in the Alternate Retirement Program unless they irrevocably waive retirement plan membership for this and any subsequent part-time employment with the University of Connecticut or with the Board of Governors of Higher Education or any other of its constituent units within 90 days of commencing employment. If you are covered by this agreement 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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