Attachment "A"

WORKSHEET REQUIRED IN CONNECTION WITH THE
1997 EARLY RETIREMENT INCENTIVE PROGRAM (ERIP)
FOR MEMBERS OF THE ALTERNATE RETIREMENT PROGRAM (ARP).

To be Completed by Agency

Section I - Alternate Retirement Program Member Identification

Member Name: ______________________Employee No. ____________________
Home Address: _____________________Social Security No.: ____________
_____________________Date of Birth: __________________
_____________________ Date of Retirement: _____________

To be Completed by Agency

Section II - Explanation of ERIP and Incentive Payments

Members of ARP retiring on or after April 1, 1997 and before August 1, 1997, who are at least fifty-two years of age on or before their retirement effective date and who have completed at least ten years of participation in the Connecticut ARP prior to their retirement effective date, are entitled to receive 12% of their final average earnings in five (5) equal annual installments paid directly to the member as follows:

12% X __________________ = __________________ / 5 = _________________
final average earnings total payment annual installment

This calculation is subject to audit and correction. The first payment will be made in October 1997 and annually thereafter with the last payment occurring in October 2001. The payments are considered taxable income and will be reported as such to the State of Connecticut Department of Revenue Services and the Internal Revenue Service; 1099R forms will be issued each year. ARP members should address any questions concerning the taxable nature of these payments to their tax advisor.


To be Completed by Member

Section III - Member Acknowledgement

I elect to participate in the 1997 ERIP and understand the provisions outlined in Section II.

Member's Signature ___________________________ Date __________________


To be Completed by Agency

Section IV - Agency Information

Agency Name ______________________________ Telephone _________________

Authorized Agency Signature ____________________________

Title _______________________________ Date ____________________


Original to Retirement & Benefit Services Division, 55 Elm Street, Hartford, CT 06106, Attention: ARP Unit; copies to agency and employee.

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