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Kevin Lembo


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Comptroller's Forms

For the PDF files included in this index:

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Click here for a separate index of Retirement Services Division Forms.

FORM NUMBER FORM NAME SOURCE DOCUMENT
Accounts Payable  
CO-17
Rev 10/2010
VENDOR INVOICE FOR GOODS OR SERVICES RENDERED TO STATE OF CONNECTICUT  
PDF format WORD format
CO-17RPC
Rev 7/15
REQUEST TO REPLENISH PETTY CASH FUND  
PDF format Word format
CO-17RPC/ADV
Rev 7/15
Record of Outstanding Petty Cash Advances  
PDF format   word format
CO-507
Rev 5/09
Lease and Rent Account Control     -       EXCEL format State Accounting Manual - Commitments
CO-512
Rev 4/2006
Claims Authorization Form
EXCEL Format
State Accounting Manual - Commitments
CO-780
Rev. 2/2008
Subscription-Order and Remittance Advice
EXCEL format
 
CO-790
Rev 11/2016
Payment Cancellation
EXCEL format
 
CO-790S
Rev 4/2006
Payment Cancellation Statement
EXCEL format
 
CO-802A
Rev 2/2008
PERSONAL SERVICE AGREEMENT PSA Standards and Procedures
PDF format WORD format
CO-860
Rev 5/2009
Request for Payment Information
EXCEL format
 
CO-924
Rev 11/2003
Postal Service Transaction State Accounting Manual - Expenditures
PDF format HTML format
SP-26NB
Rev 4/03
Agency Vendor Form - PDF format on DAS site Replaces CO-1055 - Vendor Profile Form
   
Accounts Receivable  
N/A Grant Award Report - WORD97 format  
CO-608
Rev 6/2010
INTRA-DEPARTMENT TRANSFER INVOICE  
PDF format WORD format
CO-610
Rev 4/91
RECORD OF PENDING RECEIPT State Accounting Manual - Receipts
CO-671 ADVICE OF BAD CHECKS /ACC. SYSTEM State Accounting Manual - Receipts
CP-1
Rev 9/97
Notification of Intent to Apply for Federal Assistance or Private Grant Funding - EXCEL format  
   
Employee Reimbursements  
CO-17XPA
Rev 1/2004
EMPLOYEE VOUCHER- ADDENDUM  
PDF format   Word format
CO-17XPPR
Rev 7/2009
EMPLOYEE PAYROLL REIMBURSEMENTS  
PDF format   Word format
CO-101
Rev 9/15
 
Application for Tuition Reimbursement          
PDF format
CO-102 Rev
7/2015
Tuition Priority Log  
WORD format PDF format
CO-112
Rev 5/2014
Travel Authorization Request State Accounting Manual - Commitments
WORD format  

TR-2Form
Tuition Reimbursement Authorization Form (TR-2)  
- PDF format on DAS site
 
   
Fiscal Policy and Statewide Services  
Assets and Inventory  
CO-58
02/2016
PROPERTY TRANSFER WITHIN AGENCY  
CO-59
Rev 3/16
ASSET MANAGEMENT/INVENTORY REPORT/GAAP REPORTING FORM
EXCEL format
 
CO-64
Rev 2/16
INTER-UNIT TRANSFER OF ASSETS  
WORD format
CO-65
7/05
MASS CHANGE OF ASSETS
REQUEST FORM - PDF
 
CO-648B
Rev 04/2009
SUMMARY MOTOR VEHICLE REPORT
EXCEL format
Property Control Manual
Appendix B
CO-853
Rev 4/2015
REPORT OF ADJUSTMENT TO STATE OWNED REAL AND PERSONAL PROPERTY  
Word format
CO-1079
Rev 2/2016
RECORD OF EQUIPMENT ON LOAN Property Control Manual - Appendix B
WORD format
DPS-29
Rev 2015/01
Sale Declaration Report
EXCEL
Property Control Manual
Military  
CO-11 Payroll Information Release Form  EXCEL 
CO-12 REQUEST FOR INFORMATION
EMPLOYEES RETURNING TO STATE SERVICE
FROM ACTIVE MILITARY SERVICE
 
WORD format PDF Format 
CO-13 REQUEST FOR INFORMATION REGARDING STATE EMPLOYEES IN THE RESERVES OF THE ARMED FORCES OF THE UNITED STATES 
  WORD format PDF format  
Purchasing Card  
CO-501
Rev 7/2003
P-Card Log Sheet PURCHASING CARD CARDHOLDER WORK RULES
PDF format WORD format
CO-502
Rev 7/2003
Air Travel Log Sheet AGENCY PURCHASING CARD
COORDINATOR MANUAL
PDF format WORD format
CO-503D Department Card Purchase Log Sheet - WORD format  
CO-504D Department Card User Log Sheet      -  WORD format  
Securities for Retainages  
CO-747
Rev 8/2008
Application For Substitution of Securities For Retainages
WORD format
 
Trustee Accounts  
CO-1052
Rev 7/2015
TRUSTEE ACCOUNT  
PDF format WORD format
Other  
CO-929
Rev 1/2007
BANK ACCOUNT ESTABLISHMENT REQUEST State Accounting Manual - Receipts
PDF format WORD format
 

Health Benefits

 
CO-638
Rev 8/2015
NOTICE OF DEATH - STATE EMPLOYEE  
WORD format  PDF format
CO-744
REV 7/2015
Choice of Health Services After Retirement  - WORD format  
CO-819
Rev 7/2007
APPLICATION FOR WAIVER OF GROUP LIFE INSURANCE PREMIUM PAYMENTS  
PDF format word format
CO-1048NQ
Rev 5/2012
NON-QUALIFIED CHILD (FORMER WARD) ENROLLMENT APPLICATION
WORD format
 
CO-1048RQ
Rev 5/2012
QUALIFIED DEPENDENT (FORMER WARD) ENROLLMENT APPLICATION
WORD format
 
CO-1300
Rev 07/2015
OPEB Enrollment Form - Retiree Health Fund
WORD format
 
CO-1301
Rev 07/2015
Application for Refund - Retiree Health Contributions
WORD format
 
CO-1302
Rev 07/2015
Repayment of Retiree Health Fund For Prior Service Credit  -  WORD format  
CO-1303
Rev 07/2015
Affidavit   -  WORD format  
CO-1304
Rev 07/2015
Waiver of Retiree Health Plan Participation
WORD format
 
CO-1305
Rev 07/2015
Rehired Employee's Waiver of Right to Restore Prior Service Credit for Retiree Healthcare Eligibility  
WORD format
 
CO-1306
Rev 10/2016
MEDICAL FLEXIBLE SPENDING PROGRAM (MEDFLEX)
OPEN ENROLLMENT PLAN YEAR 2016 -WORD Format
 
CO-1307
Rev 03/2014
MEDFLEX Claim Reimbursement Form -WORD Format  
CO-1308
Rev 03/2014
MEDFLEX Medical Necessity Form Letter -WORD Format  
CO-1309
Rev 03/2014
MEDFLEX Capital Expense Form -WORD Format  
CO-1310
Rev 9/2016
DEPENDENT CARE ASSISTANCE PROGRAM
OPEN ENROLLMENT PLAN YEAR 2016 -WORD Format
 
CO-1311
Rev 03/2014
Dependent Care Assistance Program Claim Reimbursement Form -
WORD Format
 
CO-1312
Rev 9/2016
Qualified Transportation Account
ENROLLMENT/CHANGE FORM - WORD Format
 
CO-1313
Rev 03/2014
PBS Claim Form - Qualified Transportation Account
WORD Format
 
CO-1314
Rev 9/2015
HEP Enrollment Form
PDF format
 
CO-1315
REV 2/2014
Emergency Room Copayment Waiver Request PDF format  
CO-1317
Rev 1/2016
For Doctors: Physician Notification Form  PDF format  
CO-1318
New 5/2012
Legal Guardianship Notification and Dependency Verification
WORD format
 
CO-1319
New 5/2012
CHANGE IN MARITAL STATUS NOTIFICATION AND CONTINUATION OF COVERAGE REQUEST
WORD format
 
CO-1321
New 7/2013
ANNUAL CERTIFICATION QUALIFIED DEPENDENT
WORD format
 
CO-1323
Rev 07/2015
RETIREE HEALTH FUND CONTRIBUTION
WORD format
 
CO-1328
Rev 7/15
RETIREE HEALTH FUND PAYMENT ADJUSTMENT  
CO-1329
9/14
Application for Refund Incorrectly Coded
Retiree Health Fund Contributions
 
 
Payroll  
CO-959
Rev 6/2006
VEHICLE USAGE FRINGE BENEFIT COMPUTATION RECORD EXCEL format  
CO-960
Rev 6/2006
VEHICLE USAGE FRINGE BENEFIT COMPUTATION RECORD/CENTS PER MILE METHOD  EXCEL format  
CO-961
Rev 6/2006
VEHICLE USAGE FRINGE BENEFIT COMPUTATION RECORD/LEASE VALUE METHOD  EXCEL format  
CO-1040
Rev 6/2008
DIRECT DEPOSIT AUTHORIZATION AND INPUT FORM   - PDF format - (Link to Core-CT website)  
CO-1081
New 10/94
AGENCY MULTI-PURPOSE PAYROLL REPORT  
COP-9
Rev 12/2015
WAGE AND DEDUCTION ADJUSTMENT FORM - WORD format - (Link to Core-CT website)  
 
Reporting  
N/A GAAP Closing Package - 2016   -  EXCEL format  
GAAP form preparation training - PowerPoint format
N/A

 
Schedule of Federal Awards (SEFA)  
Instructions for FYE June 30, 2016
- PDF format
SEFA Forms
- EXCEL format
 
Miscellaneous  
CO-931 Designation of Retirement Tier Plan Beneficiary  

This page was last updated on: December 02, 2016