INSTRUCTIONS
FOR
COMPLETION
OF
FORM CO-931, "DESIGNATION OF RETIREMENT SYSTEM-TIER-PLAN-BENEFICIARY"

Page Number
A. NEW EMPLOYEE 1
B. RE-EMPLOYED, MULTIPLE EMPLOYMENT 6
C. AGENCY TRANSFER 11
D. EMPLOYEE NAME AND/OR ADDRESS CHANGE 15
E. CHANGE IN BENEFICIARY(IES) NAME AND/OR ADDRESS 16
F. CHANGE IN RETIREMENT SYSTEM INFORMATION ONLY 17

INSTRUCTIONS FOR COMPLETION OF FORM CO-931, "DESIGNATION OF RETIREMENT SYSTEM-TIER-PLAN-BENEFICIARY"

A. NEW EMPLOYEE

This section pertains only to those employees who do not have any prior state service. For those employees who do have prior state service - regardless of when such service occurred - please refer to Section B. RE-EMPLOYED, MULTIPLE EMPLOYMENT.

IMPORTANT: A FORM CO-931 IS REQUIRED FOR EACH NEW EMPLOYEE REGARDLESS OF HIS/HER PARTICIPATION IN A RETIREMENT SYSTEM WITH THE EXCEPTION OF STATE UNIVERSITY PART-TIME LECTURERS WHO WAIVE THEIR PARTICIPATION IN A RETIREMENT PLAN OR INDIVIDUALS EMPLOYED IN THE FOLLOWING CLASSIFICATIONS EXCLUDED FROM RETIREMENT COVERAGE:

Classification Compensation Class Code
Patient/Inmate Worker 6149
State University Assistants 8105
University Student Laborer 9098
Graduate Assistant 4185
Student Laborer/Student Worker 8152

At the top of the CO-931 form, check the box labeled NEW EMPLOYEE.

Section I. EMPLOYEE INFORMATION

Complete Blocks (1) through (8) for all employees.
Complete Blocks (9) and (10) if the box labeled MARRIED is checked in Block (8).
Complete Blocks (11), (11a) and (12) for all employees.
Blocks (13) and (14) must be NO for all new employees.
Blocks (15), (16) and (17) must be blank.

Section II. RETIREMENT INFORMATION

Membership in the State Employees Retirement System Tier IIA retirement plan is mandated immediately upon employment for all state employees first hired on or after July 1, 1997 unless they are eligible to and choose membership in another state retirement system or they are employed in a classification ineligible for retirement system membership.

Teachers or professional staff members as described in Connecticut General Statutes, Section 5-160(g), first hired on or after July 1, 1997 shall be covered under Tier IIA unless they are eligible for and elect membership within six months after their employment in the Teachers Retirement System or the Alternate Retirement Program. A CO-931 form must be completed for such individuals at the time of their employment whether or not they have decided upon their retirement system election. Please see the instructions for the completion of Block (18)(h) OTHER on page four of these instructions for information on completing this section of the CO-931 form for eligible undecided employees. Following their retirement system election, a second CO-931 form must be completed for a CHANGE IN RETIREMENT SYSTEM INFORMATION ONLY.


INSTRUCTIONS FOR COMPLETION OF FORM CO-931

A. NEW EMPLOYEE continued

Page Two

For employees who are ineligible for retirement system membership, please also see the instructions for completion of Block (18)(h) OTHER on page four of these instructions.

Check the appropriate RETIREMENT SYSTEM box in Block (18).

The following instructions explain the completion of Blocks (19) through (26c) for each RETIREMENT SYSTEM.

(18)(a) STATE EMPLOYEES

(19) Must be Tier IIA for all employees first hired on or after July 1, 1997. Also check box if employee has been hired in a classification designated as hazardous duty.
(20) Must be blank for new employees.
(21) Must be either code Q for non-hazardous duty members or code D for hazardous duty members.
(22) Enter the 2 digit numeric bargaining unit code.
(23) Enter the 4 digit numeric State Personnel compensation class code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Must be blank. For ALTERNATE RETIREMENT PROGRAM use only.

(18)(b) ALTERNATE RETIREMENT PROGRAM

(19), (20) Must be blank. For STATE EMPLOYEES use only.
(21) Must be code ? for all new employees.
(22) Enter the 2 digit numeric bargaining unit code.
(23) Enter the 4 digit numeric State Personnel compensation class code.
(24), (25) Check the appropriate boxes.
(26a) Enter the name of the Insurance Company/Carrier.
(26b) Check the appropriate box for deduction election.
(26c) Enter the payroll period begin date on which the appropriate deductions will start.

(18)(c) JUDGES, FAMILY SUPPORT MAGISTRATES & COMPENSATION COMMISSIONERS

(19), (20) Must be blank. For STATE EMPLOYEES use only.
(21) Must be either code X for Judges or code Z for Family Support Magistrates and Compensation Commissioners.
(22) Enter the 2 digit numeric bargaining unit code.
(23) Enter the 4 digit numeric State Personnel compensation class code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Must be blank. For ALTERNATE RETIREMENT PROGRAM use only.


INSTRUCTIONS FOR COMPLETION OF FORM CO-931

A. NEW EMPLOYEE continued

Page Three

(18)(d) PROBATE COURT JUDGES & EMPLOYEES

(19), (20) Must be blank. For STATE EMPLOYEES use only.
(21) Must be code 4.
(22) Must be blank.
(23) Enter the 4 digit numeric Probate Court District identification code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Must be blank. For ALTERNATE RETIREMENT PROGRAM use only.

(18)(e) PUBLIC DEFENDERS

(19), (20) Must be blank. For STATE EMPLOYEES use only.
(21) Must be code 6.
(22) Enter the 2 digit numeric bargaining unit code.
(23) Enter the 4 digit numeric State Personnel compensation class code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Must be blank. For ALTERNATE RETIREMENT PROGRAM use only.

(18)(f) STATES ATTORNEY

(19), (20) Must be BLANK. For STATE EMPLOYEES use only.
(21) Must be code Y.
(22) Enter the 2 digit numeric bargaining code.
(23) Enter the 4 digit numeric State Personnel compensation class code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Must be blank. For ALTERNATE RETIREMENT PROGRAM use only.

(18)(g) TEACHERS RETIREMENT SYSTEM

(19), (20) Must be blank. For STATE EMPLOYEES use only.
(21) Must be either code E or code F.
(22) Enter the 2 digit numeric bargaining unit code.
(23) Enter the 4 digit numeric State Personnel compensation class code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Must be blank. For ALTERNATE RETIREMENT PROGRAM use only.


INSTRUCTIONS FOR COMPLETION OF FORM CO-931

A. NEW EMPLOYEE continued

Page Four

(18)(h) OTHER

Please specify "Ineligible"or "Undecided".

(19), (20) Must be blank. For STATE EMPLOYEES use only.
(21) Must be either code 0 - no FICA or code 3 - FICA for employees ineligible for retirement system membership.
Must be code U for employees eligible to choose within six months of their date of employment membership in either the State Employees Retirement System, the Teachers Retirement System or the Alternate Retirement Program who are undecided. Upon making a decision to elect membership in one of these three systems, a CO-931 form for a RETIREMENT SYSTEM INFORMATION CHANGE ONLY must be completed.

Please note: for undecided employees who choose membership in the State Employees Retirement System, such membership will be retroactive to their date of employment; mandatory Tier IIA retirement contributions will be due from the employee=s date of employment to the date with which the appropriate retirement contribution deductions are begun.
(22) Enter the 2 digit numeric bargaining unit code.
(23) Enter the 4 digit numeric State Personnel compensation class code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Must be blank. For ALTERNATE RETIREMENT PROGRAM use only.

Section III. BENEFICIARY INFORMATION

If an employee does not choose to designate a beneficiary, any monies payable upon the employee's death will be refunded to his/her estate.

If an employee designates more than one beneficiary and does not specify a percentage, each beneficiary will receive an equal share of the employee=s monies.

If an employee chooses to designate a primary and contingent beneficiary, he/she must check the box labeled contingent to identify the contingent beneficiary.

If an employee chooses to designate more than four beneficiaries, check the box on the CO- 931 form and attach a second CO-931 form listing the additional beneficiaries.

Complete Blocks (27) through (33) for each designated beneficiary.

Please note: It is especially important that Block (33) DATE OF BIRTH be completed if the designated beneficiary is a minor child as the method of payment to a minor payee is statutorily mandated.


INSTRUCTIONS FOR COMPLETION OF FORM CO-931

A. NEW EMPLOYEE continued

Page Five

Section IV. MEMBER'S STATEMENT

The employee must sign and date the CO-931 form in Blocks (34) and (35).

An authorized agency staff member must sign and date the CO-931 form and provide their title and telephone number in Blocks (36) through (38).


INSTRUCTIONS FOR COMPLETION OF FORM CO-931

Page Six

B. RE-EMPLOYED, MULTIPLE EMPLOYMENT

This section pertains to those employees who were previously employed in state service, terminated their employment, and are now being re-employed OR who retired from State service and are being either permanently or temporarily re-employed OR who are currently and will continue to be dually employed at another State agency.

If the employee is transferring their employment from another agency or another MSA payroll level 2 within the same agency, please refer to Section C. AGENCY TRANSFER.

At the top of the CO-931 form, check the box labeled RE-EMPLOYED, MULTIPLE EMPLOYMENT.

Section I. EMPLOYEE INFORMATION

Complete Blocks (1) through (8) for all employees.
Note: Contact State Personnel or the Retirement & Benefit Services Division, Data Base Unit, to obtain the employee number originally assigned to the employee. Do not assign a new number.
Complete Blocks (9) and (10) if the box labeled MARRIED is checked in Block (8).
Complete Blocks (11), (11a) and (12) for all employees.
Block (13) must be completed for employees currently working at another State agency.
Block (14) must be YES for all re-employed employees.
Complete Blocks (15), (16) and (17).

Section II. RETIREMENT INFORMATION

Teachers or professional staff members as described in Connecticut General Statutes, Section 5-160(g), shall be covered under the State Employees Retirement System Tier I, Tier II or Tier IIA retirement plan, dependent upon their appropriate Tier placement, unless they are eligible for and elect membership within six months after their employment in the Teachers Retirement System or the Alternate Retirement Program. A CO-931 form must be completed for such individuals at the time of their employment whether or not they have decided upon their retirement system election. Please see the instructions for the completion of Block (18)(h) OTHER on page nine of these instructions for information on completing this section of the CO-931 form for eligible undecided employees. Following their retirement system election, a second CO-931 form must be completed for a CHANGE IN RETIREMENT SYSTEM INFORMATION ONLY.

For employees who are ineligible for retirement system membership, please also see the instructions for completion of Block (18)(h) OTHER on page nine of these instructions.

Temporarily re-employed State Employees Retirement System (SERS) retirees may work a maximum of 120 days in a calendar year without engaging the pension suspension provisions of Connecticut General Statutes, Section 5-164a (c). Please also see the instructions for completion of Block (18)(h) OTHER on page nine of these instructions for information on completing this section of the CO-931 form for such retirees.


INSTRUCTIONS FOR COMPLETION OF FORM CO-931

B. RE-EMPLOYED, MULTIPLE EMPLOYMENT continued

Page Seven

SERS Tier I retirees who are re-employed on a permanent basis may elect to resume their SERS membership and make any required contributions to the retirement fund upon completion of not less than six months of continuous service. A CO-931 form which reflects no retirement system membership must be completed for such individuals at the time of their re-employment. Please see the instructions for the completion of Block (18)(h) OTHER on page nine of these instructions for information on completing this section of the CO-931 form for permanently re-employed Tier I retirees. Following their retirement system election, a second CO-931 form must be completed for a CHANGE IN RETIREMENT SYSTEM INFORMATION ONLY.

SERS Tier II and Tier IIA retirees who are re-employed on a permanent basis must complete a CO-931 form immediately resuming their SERS membership at the time of their reemployment.

For individuals currently employed at another state agency, unless they are eligible to and elect membership in another state retirement system, their SERS tier and plan membership in their new employment must agree with their existing employment SERS tier and plan membership.

Check the appropriate RETIREMENT SYSTEM box in Block (18).

The following instructions explain the completion of Blocks (19) through (26c) for each RETIREMENT SYSTEM.

(18)(a) STATE EMPLOYEES

(19) May be Tier I, Tier II or Tier IIA dependent upon the employee=s prior retirement system membership, the length of their prior service credit and the length of their break in service. Also check box if employee has been hired in a classification designated as hazardous duty. Dually employed SERS members must reflect the same tier and plan membership as was designated for their already existing employment. Contact the Retirement & Benefit Services Division, Data Base Unit, if you have any questions regarding the appropriate Tier placement for a re-employed employee.
Please note: Employees returning to Tier II membership must also complete and submit, along with the CO-931 form a Form CO-922, "Retirement Credit - Tier II Members Only".
(20) Complete only if Tier I is checked in Block (19). Employee must return to their former Tier I retirement plan membership.
(21) Enter the appropriate retirement code based upon the employee's Tier placement and hazardous duty status. Contact the Retirement & Benefit Services Division, Data Base Unit, if you have any questions regarding the appropriate retirement code.
(22) Enter the 2 digit numeric bargaining unit code.
(23) Enter the 4 digit numeric State Personnel compensation class code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Must be blank. For ALTERNATE RETIREMENT PROGRAM use only.


INSTRUCTIONS FOR COMPLETION OF FORM CO-931

B. RE-EMPLOYED, MULTIPLE EMPLOYMENT continued

Page Eight

(18)(b) ALTERNATE RETIREMENT PROGRAM

(19), (20) Must be blank. For STATE EMPLOYEES use only.
(21) Must be code ? for all new ARP members. Code = may be appropriate for certain members based upon their prior ARP service. Contact the Retirement & Benefit Services, Data Base Unit, if you have any questions regarding the appropriate retirement code.
(22) Enter the 2 digit numeric bargaining unit code.
(23) Enter the 4 digit numeric State Personnel compensation class code.
(24), (25) Check the appropriate boxes.
(26a) Enter the name of the Insurance Company/Carrier.
(26b) Check the appropriate box for deduction election.
(26c) Enter the payroll period begin date on which the appropriate deductions will start.

(18)(c) JUDGES, FAMILY SUPPORT MAGISTRATES & COMPENSATION COMMISSIONERS

(19), (20) Must be blank. For STATE EMPLOYEES use only.
(21) Must be either X for Judges or code Z for Family Support Magistrates and Compensation Commissioners.
(22) Enter the 2 digit numeric bargaining unit code.
(23) Enter the 4 digit numeric State Personnel compensation class code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Must be blank. For ALTERNATE RETIREMENT PROGRAM use only.

(18)(d) PROBATE COURT JUDGES & EMPLOYEES

(19), (20) Must be blank. For STATE EMPLOYEES use only.
(21) Must be code 4.
(22) Must be blank.
(23) Enter the 4 digit numeric Probate Court District identification code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Must be blank. For ALTERNATE RETIREMENT PROGRAM use only.

(18)(e) PUBLIC DEFENDERS

(19),(20) Must be blank. For STATE EMPLOYEES use only.
(21) Must be code 6.
(22) Enter the 2 digit numeric bargaining unit code.
(23) Enter the 4 digit numeric State Personnel compensation class code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Must be blank. For ALTERNATE RETIREMENT PROGRAM use only.


INSTRUCTIONS FOR COMPLETION OF FORM CO-931

B. RE-EMPLOYED, MULTIPLE EMPLOYMENT continued

Page Nine

(18)(f) STATES ATTORNEY

(19), (20) Must be BLANK. For STATE EMPLOYEES use only.
(21) Must be code Y.
(22) Enter the 2 digit numeric bargaining code.
(23) Enter the 4 digit numeric State Personnel compensation class code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Must be blank. For ALTERNATE RETIREMENT PROGRAM use only.

(18)(g) TEACHERS RETIREMENT SYSTEM

(19), (20) Must be blank. For STATE EMPLOYEES use only.
(21) Must be either code E or code F.(22) Enter the 2 digit numeric bargaining unit code.
(23) Enter the 4 digit numeric State Personnel compensation class code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Must be blank. For ALTERNATE RETIREMENT PROGRAM use only.

(18)(h) OTHER

Please specify "Ineligible", "Undecided", "Temporarily Re-employed Retiree" or "Permanently Re-employed Retiree - 1st Six Months".

(19), (20) Must be blank. For STATE EMPLOYEES use only.
(21) Must be either code 0 - no FICA or code 3 - FICA for employees ineligible for retirement systemmembership.
Must be code U for employees eligible to choose within six months of their date of employment membership in either the State Employees Retirement System, the Teachers Retirement System or the Alternate Retirement Program who are undecided. Upon making a decision to elect membership in one of these three systems, a CO-931 form for a RETIREMENT SYSTEM INFORMATION CHANGE ONLY must be completed.
Please note: for employees who chose membership in the State Employees Retirement System, if their appropriate Tier placement is in the Tier I or Tier IIA contributory retirement plans, mandatory retirement contributions will be due from the employee=s date of employment to the date with which the appropriate retirement contribution deductions are begun.
Must be either code K for a temporarily reemployed SERS Tier I or ARP retiree or code P for a temporarily reemployed SERS Tier II retiree.
Must be code 3 for a retired SERS Tier I member who is being reemployed on a permanent basis until they have completed six months of continuous employment at which time they must complete a second CO-931 form for a CHANGE IN RETIREMENT SYSTEM INFORMATION ONLY reflecting their resumption of retirement plan membership.


INSTRUCTIONS FOR COMPLETION OF FORM CO-931

B. RE-EMPLOYED, MULTIPLE EMPLOYMENT continued

Page Ten

(22) Enter the 2 digit numeric bargaining unit code.
(23) Enter the 4 digit numeric State Personnel compensation class code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Must be blank. For ALTERNATE RETIREMENT PROGRAM use only.

Section III. BENEFICIARY INFORMATION

If an employee does not choose to designate a beneficiary, any monies payable upon the employee=s death will be refunded to his/her estate.

If an employee designates more than one beneficiary and does not specify a specific percentage, each beneficiary will receive an equal share of the employee=s monies.

If an employee chooses to designate a primary and contingent beneficiary, he/she must check the box labeled contingent to identify the contingent beneficiary.

If an employee chooses to designate more than four beneficiaries, check the box on the CO- 931 form and attach a second CO-931 form listing the additional beneficiaries.

Complete Blocks (27) through (33) for each designated beneficiary.

Please note: It is especially important that Block (33) DATE OF BIRTH be completed if the designated beneficiary is a minor child as the method of payment to a minor payee is statutorily mandated.

Section IV. MEMBER'S STATEMENT

The employee must sign and date the CO-931 form in Blocks (34) and (35).

An authorized agency staff member must sign and date the CO-931 form and provide their title and telephone number in Blocks (36) through (38).


INSTRUCTIONS FOR COMPLETION OF FORM CO-931

Page Eleven

C. AGENCY TRANSFER

This section pertains only to those employees who are making an immediate transfer to another agency or another MSA payroll level 2 within the same agency without any break in service.

At the top of the CO-931 form, check the box labeled AGENCY TRANSFER.

Section I. EMPLOYEE INFORMATION

Complete Blocks (1) through (8) for all employees.
Complete Blocks (9) and (10) if the box labeled MARRIED is checked in Block
(8).
Complete Blocks (11), (11a), and (12) for all employees.
Block 13 should be NO for agency transfers. If the individual is dually employed refer to B. RE-EMPLOYED on page five of these instructions.
Complete Blocks (14) through (15) with information from the former agency.
Block (16) Should be one day before the Date of Employment in Block (4).

Section II. RETIREMENT INFORMATION

A SERS member who is making a direct transfer from one State agency to another must retain the same Tier and plan membership unless they are eligible to and elect membership in another State retirement system such as the Alternate Retirement Program or the Teachers' Retirement System or have a change in their job classification either from a classification designated as hazardous duty to a non-hazardous duty classification or the reverse.

An ARP member who is making a direct transfer from one State agency to another must retain their ARP membership unless they transfer to a job classification not eligible for ARP membership.

Check the appropriate RETIREMENT SYSTEM box in Block (18).

The following instructions explain the completion of Blocks (19) through (26c) for each RETIREMENT SYSTEM.

(18)(a) STATE EMPLOYEES

(19) Must be Tier I, Tier II or Tier IIA dependent upon employee=s previous membership. Also check box if employee has been hired in a classification designated as hazardous duty.
(20) Complete only if Tier I is checked in Block (19).
(21) Enter the appropriate retirement code based upon the employee's Tier placement and hazardous duty status. Contact the Retirement & Benefit Services Division, Data Base Unit, if you have any questions regarding the appropriate retirement code.
(22) Enter the 2 digit numeric bargaining unit code.
(23) Enter the 4 digit numeric State Personnel compensation class code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Must be blank. For ALTERNATE RETIREMENT PROGRAM use only.


INSTRUCTIONS FOR COMPLETION OF FORM CO-931

C. AGENCY TRANSFER continued

Page Twelve

(18)(b) ALTERNATE RETIREMENT PROGRAM

(19), (20) Must be blank. For STATE EMPLOYEES use only.
(21) Must be code ? for all new ARP members. Code = may be appropriate for certain members based upon prior ARP service. Contact the Retirement & Benefit Services, Data Base Unit, if you have any questions regarding the appropriate retirement code.
(22) Enter the 2 digit numeric bargaining unit code.
(23) Enter the 4 digit numeric State Personnel compensation class code.
(24), (25) Check the appropriate boxes.
(26a) Enter the name of the Insurance Company/Carrier.
(26b) Check the appropriate box for deduction election.
(26c) Enter the payroll period begin date on which the appropriate deductions will start.

(18)(c) JUDGES, FAMILY SUPPORT MAGISTRATES & COMPENSATION COMMISSIONERS

(19), (20) Must be blank. For STATE EMPLOYEES use only.
(21) Must be either code X for Judges or code Z for Family Support Magistrates and CompensationCommissioners.
(22) Enter the 2 digit numeric bargaining unit code.
(23) Enter the 4 digit numeric State Personnel compensation class code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Must be blank. For ALTERNATE RETIREMENT PROGRAM use only.

(18)(d) PROBATE COURT JUDGES & EMPLOYEES

(19), (20) Must be blank. For STATE EMPLOYEES use only.
(21) Must be code 4.
(22) Must be blank.
(23) Enter the 4 digit numeric Probate Court District identification code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Must be blank. For ALTERNATE RETIREMENT PROGRAM use only.

(18)(e) PUBLIC DEFENDERS

(19), (20) Must be blank.
For STATE EMPLOYEES use only.
(21) Must be code 6.
(22) Enter the 2 digit numeric bargaining unit code.
(23) Enter the 4 digit numeric State Personnel compensation class code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Must be blank. For ALTERNATE RETIREMENT PROGRAM use only.


INSTRUCTIONS FOR COMPLETION OF FORM CO-931

C. AGENCY TRANSFER continued

Page Thirteen

(18)(f) STATES ATTORNEY

(19), (20) Must be BLANK. For STATE EMPLOYEES use only.
(21) Must be code Y.
(22)Enter the 2 digit numeric bargaining code.
(23) Enter the 4 digit numeric State Personnel compensation class code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Must be blank. For ALTERNATE RETIREMENT PROGRAM use only.

(18)(g) TEACHERS RETIREMENT SYSTEM

(19), (20) Must be blank. For STATE EMPLOYEES use only.
(21) Must be either code E or code F.(22) Enter the 2 digit numeric bargaining unit code.
(23) Enter the 4 digit numeric State Personnel compensation class code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Must be blank. For ALTERNATE RETIREMENT PROGRAM use only.

(18)(h) OTHER

Please specify "Ineligible".

(19), (20) Must be blank. For STATE EMPLOYEES use only.
(21) Must be either code 0 - no FICA or code 3 - FICA for employees ineligible for retirement system membership. Contact the Retirement & Benefit Services Division, Data Base Unit, if you have any questions regarding the appropriate retirement code.
(22) Enter the 2 digit numeric bargaining unit code.
(23) Enter the 4 digit numeric State Personnel compensation class code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Must be blank. For ALTERNATE RETIREMENT PROGRAM use only.

Section III. BENEFICIARY INFORMATION

When transferring from one State agency to another, an employee may designate new beneficiaries if he/she so desires. If an employee does not choose to designate new beneficiaries, any previous designations will remain in effect.

If an employee does not choose to designate a beneficiary upon transfer and has not made an earlier designation, any monies payable upon the employee=s death will be refunded to his/her estate.

If an employee designates more than one beneficiary and does not specify a specific percentage, each beneficiary will receive an equal share of the employee=s monies.


INSTRUCTIONS FOR COMPLETION OF FORM CO-931

C. AGENCY TRANSFER continued

Page Fourteen

If an employee chooses to designate a primary and contingent beneficiary, he/she must check the box labeled contingent to identify the contingent beneficiary.

If an employee chooses to designate more than four beneficiaries, check the box on the CO- 931 form and attach a second CO-931 form listing the additional beneficiaries.

Complete Blocks (27) through (33) for each designated beneficiary.

Please note: It is especially important that Block (33) DATE OF BIRTH be completed if the designated beneficiary is a minor child as the method of payment to a minor payee is statutorily mandated.

Section IV. MEMBER'S STATEMENT

The employee must sign and date the CO-931 form in Blocks (34) and (35).

An authorized agency staff member must sign and date the CO-931 form and provide their title and telephone number in Blocks (36) through (38).


INSTRUCTIONS FOR COMPLETION OF FORM CO-931

Page Fifteen

D. EMPLOYEE NAME AND/OR ADDRESS CHANGE

At the top of the CO-931 form, check the box labeled EMPLOYEE NAME AND/OR ADDRESS CHANGE.

Underline or circle the action(s) which applies to the type of change(s) being made.

Any name and address changes that have been processed through the Department of Administrative Services' Automated Personnel System (APS) will be automatically updated in the State Employees Data Base on the first Tuesday of every month as described in Retirement & Benefit Services Division memorandum dated February 1, 1996. Therefore, completion of a CO-931 form will not be necessary for individuals employed at agencies utilizing APS.

Section I. EMPLOYEE INFORMATION

Complete Blocks (1),(2), and (3).
Complete Block (7) for a change of address.
Complete Blocks (8), (9) and (10) for a name and marital status change.
Complete Blocks (11), (11a) and (12).
Complete Block (17) for a name change.

Section IV. MEMBER'S STATEMENT

The employee must sign and date the CO-931 form in Blocks (34) and (35).

An authorized agency staff member must sign and date the CO-931 form and provide their title and telephone number in Blocks (36) through (38).


INSTRUCTIONS FOR COMPLETION OF FORM CO-931

Page Sixteen

E. CHANGE IN BENEFICIARY(IES) NAME AND /OR ADDRESS

Any CO-931 form received for a change in beneficiary(ies) represents a permanent change in the member's beneficiary designation. Any and all former designations are revoked and the new designation will remain in effect unless the member subsequently provides written notice to the Retirement & Benefit Services Division changing their beneficiary designation.

At the top of the CO-931 form, check the box labeled CHANGE IN BENEFICIARY(IES) NAME AND/OR ADDRESS

Section I. EMPLOYEE INFORMATION

Complete Blocks (1), (2), (3), (11), (11a) and (12).

Section III. BENEFICIARY INFORMATION

If an employee designates more than one beneficiary and does not specify a specific percentage, each beneficiary will receive an equal share of the employee=s monies.

If an employee chooses to designate a primary and contingent beneficiary, he/she must check the box labeled contingent to identify the contingent beneficiary.

If an employee chooses to designate more than four beneficiaries, check the box on the CO- 931 form and attach a second CO-931 form listing the additional beneficiaries.

Complete Blocks (27) through (33) for each designated beneficiary.

Please note: It is especially important that Block (33) DATE OF BIRTH be completed if the designated beneficiary is a minor child as the method of payment to a minor payee is statutorily mandated.

Section IV. MEMBER'S STATEMENT

The employee must sign and date the CO-931 form in Blocks (34) and (35).

An authorized agency staff member must sign and date the CO-931 form and provide their title and telephone number in Blocks (36) through (38).


INSTRUCTIONS FOR COMPLETION OF FORM CO-931

Page Seventeen

F. CHANGE IN RETIREMENT SYSTEM INFORMATION ONLY

This section pertains only to those employees who are changing retirement system, tier, and/or plan membership as a result of a change in their employment status which either necessitates such change or provides the employee with an option not previously available. A CO-931 form with this action designated must be provided for 1) employees who within the same agency have a change in their job classification either from a classification designated as hazardous duty to a non-hazardous duty classification or the reverse, 2) employees who again within the same agency have a change in their job classification which affords them the opportunity not previously available to chose membership in the Alternate Retirement Plan (ARP) or Teachers Retirement System (TRS) or necessitates a transfer from ARP or TRS to SERS membership, 3) permanently re-employed SERS Tier I retirees who have completed six months of employment and are electing to resume their Tier I retirement plan membership and 4) corrections of previous tier placement errors.

At the top of the CO-931 form, check the box labeled CHANGE IN RETIREMENT INFORMATION ONLY.

Section I. EMPLOYEE INFORMATION

Complete Blocks (1), (2) AND (3).
Enter the effective date of the retirement system change in Block (4).
Complete Blocks (11), (11a), (12) and (13).

Section II. RETIREMENT INFORMATION

Complete Blocks (18) through (26c) as applicable.

Please contact the Retirement & Benefit Services Division, Data Base Unit, if you have any questions regarding the appropriate retirement information.

Section IV. MEMBER'S STATEMENT

The employee must sign and date the CO-931 form in Blocks (34) and (35).

An authorized agency staff member must sign and date the CO-931 form and provide their title and telephone number in Blocks (36) through (38).

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