Attachment "H"

Name:
Employee No.:
Date of Retirement:

STATE EMPLOYEES RETIREMENT COMMISSION
PROOF OF BIRTH
AFFIDAVIT

STATE OF CONNECTICUT )
)ss
COUNTY OF )

______________________________________ being duly sworn, deposes and says:

  1. I am unable to comply with the rule of the State Employees Retirement Commission of the State of Connecticut requiring the filing of a properly attested certificate of my birth.
  2. To the best of my knowledge and belief I was born at
    ___________________________________ on the ______ day of ___________________ , 19 ____ .
  3. In lieu of said certificate, I hereby accept and irrevocably establish said date as my correct and legal date of birth for all purposes of the State of Connecticut.
__________________________________________
Signature

Subscribed and sworn to
before me this ________________
day of ___________________ 19 ____ .

____________________________
Notary Public
Commissioner of the Superior Court

PLEASE NOTE

In addition to the completed affidavit, you must submit two (2) documents, as described on the instruction sheet provided to you, which support your claim of your exact birthdate.

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