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Comptroller's Retirement Services Division Forms

For the PDF files included in this index:

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Retirement Services Division Forms are continually being updated and redesigned. We welcome your suggestions as to format or wording. Please send your comments to osc.rsd@po.state.ct.us

Most of these forms have been designed to allow you to complete the form online and then print the form for any necessary signatures.  You may also print a blank copy of any of these forms to be completed manually.

Audit Unit
FORM
NUMBER		 CATALOG
NUMBER		 FORM NAME FILE
SIZE		 SOURCE DOCUMENT
CO-898
New 2/09		 N/A APPLICATION FOR RETIREMENT BENEFITS
WORD format		    
CO-899
Rev 11/08		 N/A INCOME PAYMENT ELECTION FORM - OPTION A
- 50% SPOUSE 		   
PDF format WORD format
CO-900
Rev 05/09		 N/A INCOME PAYMENT ELECTION FORM - OPTION B
- 50% OR 100% SURVIVOR		    
PDF format WORD format
CO-901
Rev 11/08		 N/A INCOME PAYMENT ELECTION FORM - OPTION C
- 10 TO 20 YEARS PERIOD CERTAIN 		   
PDF format WORD format
CO-902
Rev 11/08		 N/A INCOME PAYMENT ELECTION FORM - OPTION D - STRAIGHT LIFE ANNUITY    
PDF format WORD format
CO-1047
Rev 05/09		 N/A SPOUSE WAIVER OF MONTHLY SURVIVOR BENEFITS    
PDF format WORD format
CO-1068
Rev 8/2011		 N/A RETIREMENT - DIRECT DEPOSIT AUTHORIZATION AND INPUT FORM 93KB  
PDF format  WORD Format


Database Unit
FORM
NUMBER		 CATALOG
NUMBER		 FORM NAME FILE
SIZE		 SOURCE DOCUMENT
CO-628
Rev 3/2009		 N/A APPLICATION FOR REFUND OF RETIREMENT CONTRIBUTIONS  - SERS, Tier I Members Only and Probate Judges & Employees Retirement System Members - WORD format    
CO-628a
New 3/2009		 N/A APPLICATION FOR REFUND OF RETIREMENT CONTRIBUTIONS  -Tier II Hazardous Duty Members Only 
WORD format		    
CO-628b
New 3/2009		 N/A APPLICATION FOR REFUND OF RETIREMENT CONTRIBUTIONS  - Tier IIA Members - Non Vested Only
WORD format		    
CO-628c
New 3/2009		 N/A APPLICATION FOR REFUND OF HAZARDOUS DUTY RETIREMENT CONTRIBUTIONS 
WORD format		    
CO-931
Rev 12/11		 NA DESIGNATION OF RETIREMENT SYSTEM- TIER-PLAN-BENEFICIARY
 		 35 Kb

Retirement Services Division Memo 2012-01
Dated January 3, 2012
CO-931h
Rev 12/11		 N/A DESIGNATION OF RETIREMENT SYSTEM- TIER-PLAN-BENEFICIARY- HIGHER EDUCATION
 		  

Retirement Services Division Memo 2012-01
Dated January 3, 2012
CO-1208
Rev 2/2011		 N/A TEMPORARY POST RETIREMENT REEMPLOYMENT
WORD format		 70 Kb  

 
Legal Documents
FORM
NUMBER		 CATALOG
NUMBER		 FORM NAME FILE
SIZE		 SOURCE DOCUMENT
CO-1049
New 5/2009		 N/A LIMITED DURABLE POWER OF ATTORNEY (LDPOA) - PRE RETIREMENT    
PDF format WORD format
CO-1049A
New 5/2009		 N/A LIMITED DURABLE POWER OF ATTORNEY (LDPOA) - POST RETIREMENT    
PDF format WORD format

CO-1060
New 7/2009		 N/A FINANCIAL AFFIDAVIT FORM
Explanation- Word format		    
PDF format WORD format


Miscellaneous Unit
FORM
NUMBER		 CATALOG
NUMBER		 FORM NAME FILE
SIZE		 SOURCE DOCUMENT
CO-898a
New 6/09		 N/A APPLICATION FOR ALTERNATE RETIREMENT PROGRAM RETIREMENT BENEFITS
WORD format		    
CO-898P
NEW 6/2010		 N/A APPLICATION FOR RETIREMENT BENEFITS  - WORD format 209Kb  
CO-899P
New 12/09		 N/A INCOME PAYMENT ELECTION FORM - OPTION A
- 50% SPOUSE 		   
WORD format
CO-900P
New 12/09		 N/A INCOME PAYMENT ELECTION FORM - OPTION B
- 50% OR 100% SURVIVOR		    
WORD format
CO-901P
New 12/09		 N/A INCOME PAYMENT ELECTION FORM - OPTION C
- 10 TO 20 YEARS PERIOD CERTAIN 		   
WORD format
CO-902P
New 12/09		 N/A INCOME PAYMENT ELECTION FORM - OPTION D
- STRAIGHT LIFE ANNUITY		    
WORD format
CO-931J
New 12/11		 N/A DESIGNATION OF RETIREMENT SYSTEM-TIER-PLAN-BENEFICIARY
JUDICIAL BRANCH		  

Retirement Services Division Memo 2012-01
Dated January 3, 2012
WORD format
CO-931P
New 12/11		 N/A DESIGNATION OF RETIREMENT SYSTEM-TIER-PLAN-BENEFICIARY
PROBATE JUDGES AND EMPLOYEES		    
WORD format
CO-1047P
New 12/09		 N/A SPOUSE WAIVER OF MONTHLY SURVIVOR BENEFITS    
WORD format


Purchasing Unit
FORM
NUMBER		 CATALOG
NUMBER		 FORM NAME FILE
SIZE		 SOURCE DOCUMENT
CO-991
New 2/2012		 N/A  FOR TIER III MEMBERS ONLY  - 
RETIREMENT CREDIT PURCHASE REQUEST- PRIOR MISC SERVICE
Word format		 2173 Kb  
CO-992
New 2/2012		 N/A  REEMPLOYED TIER III MEMBERS ONLY  -
RETIREMENT CREDIT RESTORATION REQUEST
Word format		 2152 Kb
 		  
CO-993
New 2/2012 		N/A  TIER III MEMBERS ONLY  -
RETIREMENT CREDIT PURCHASE REQUEST- FOR QUALIFYING LEAVES WITHOUT PAY     Word format		 2153 Kb
 		  
CO-1088
New 8/98		 800-10  RETIREMENT CREDIT PURCHASE REQUEST- PRIOR MISC SERVICE
PDF format		 75 Kb Purchasing Unit
Retirement Division Tier 2A Memorandum
CO-1089
New 8/98		 800-11  RETIREMENT CREDIT RESTORATION REQUEST
PDF format		 67 Kb
 		 Purchasing Unit
Retirement Division Tier 2A Memorandum
CO-1090
New 8/98		 800-12 RETIREMENT CREDIT PURCHASE REQUEST- LEAVES WITHOUT PAY
PDF format		 69 Kb
 		 Purchasing Unit
Retirement Division Tier 2A Memorandum


Retirement Payroll Unit
FORM
NUMBER		 CATALOG
NUMBER		 FORM NAME FILE
SIZE		 SOURCE DOCUMENT
CO-1082
Rev 9/2010		 N/A RETIREE/ANNUITANT ADDRESS CHANGE FORM 15 Kb  
PDF format WORD format
CO-1093
Rev 9/2010		 N/A FEDERAL AND CONNECTICUT TAX WITHHOLDING CHANGE  FORM 38 Kb  
PDF format WORD format


Municipal Employees Retirement System (MERS) Unit
FORM
NUMBER		 CATALOG
NUMBER		 FORM NAME FILE
SIZE		 SOURCE DOCUMENT
CO-1200
Rev 9/2010		 N/A APPLICATION FOR MERS RETIREMENT BENEFITS  (PART B) 22 KB MERS Unit
PDF format WORD format
CO-1201
Rev 10/2009		 N/A MERS INCOME PAYMENT ELECTION FORM - Option A   MERS Unit
PDF format WORD format
CO-1202
Rev 10/2009		 N/A MERS INCOME PAYMENT ELECTION FORM - Option B   MERS Unit
PDF format WORD format
CO-1203
Rev 10/2009		 N/A MERS INCOME PAYMENT ELECTION FORM - Option C   MERS Unit
PDF format WORD format
CO-1204
Rev 10/2009		 N/A MERS INCOME PAYMENT ELECTION FORM - Option D   MERS Unit
PDF format WORD format
CO-1205
Rev 10/2009		 N/A SPOUSE WAIVER OF MONTHLY SURVIVOR BENEFIT (MERS)   MERS Unit
PDF format WORD format
CO-1206
New 10/2009		 N/A CERTIFICATION OF MARITAL STATUS (MERS)   MERS Unit
PDF format WORD format
CO-1207
Rev 06/2011		 N/A APPLICATION FOR MERS RETIREMENT BENEFITS (PART A) 225KB MERS Unit
PDF format WORD format
CO-1209
Rev 06/2011		 N/A ACKNOWLEDGEMENT  FORM - SCD  (MERS) 81 KB MERS Unit
PDF format WORD format
CO-1210
New 11/2010		 N/A RETIREE/ANNUITY ADDRESS CHANGE FORM  (MERS) 51 Kb MERS Unit
PDF format WORD format
CO-1211
New 11/2010		 N/A FEDERAL AND CONNECTICUT WITHHOLDING TAX CHANGE FORM  (MERS) 81 Kb MERS Unit
PDF format WORD format
CO-1212
New 06/2011		 N/A MERS APPLICATION FOR REFUND OF RETIREMENT CONTRIBUTIONS FOR NON-VESTED MEMBERS 240 Kb MERS Unit
PDF format WORD format
CO-1213
New 06/2011		 N/A APPLICATION FOR DISABILITY RETIREMENT  -
MEMBER'S STATEMENT		 173 Kb MERS Unit
PDF format WORD format
CO-1214
New 06/2011		 N/A APPLICATION FOR DISABILITY RETIREMENT  -
PHYSICIAN'S STATEMENT		 124 Kb MERS Unit
PDF format WORD format
CO-1215
New 06/2011		 N/A APPLICATION FOR DISABILITY RETIREMENT  -
EMPLOYER'S STATEMENT		 162 Kb MERS Unit
PDF format WORD format

This page was last updated on: February 03, 2012

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