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State Retirees Municipal Employees Probate Retirees Higher Ed Retirees
CMERS

for a full list of Comptroller's forms, click here

COMMONLY USED FORMS

You can "click" on the name of the form shown below and will be directed to either a "fillable" form on the OSC website or a PDF of that form.

Initial Employment Forms - Must Be Completed (or Completed in Part) by CMERS Employers and forwarded to CMERS by the Employer

Form CO-931, "Designation of Retirement System-Tier-Plan-Beneficiary"

This form must be completed by each new member enrolling in the MERS on and after July 1, 2007. Thereafter, the Form CO-931 must be completed by members with name, address and/or beneficiary changes. The municipality must also complete the signature section of each Form CO-931 (specifically, numbers 36, 37 and 38) and send the fully completed forms to the MERS Unit. - Please note that employee contributions will be made on a post tax basis unless the municipality elects that such contributions be made on a pre-tax basis.

Social Security - Form SSA 1945

If your CMERS town or agency is not covered by social security (i.e. CMERS Part A) you need to submit an executed Form SSA 1945 to MERS with the employee's CO-931 for all new employees hired after January 1, 2005. Copies of the SSA-1945 are available online at the Social Security website, www.socialsecurity.gov/form1945

Form CO-923 - Monthly Contributions

This form is the monthly MERS report which details the ongoing monthly contributions of the employer and the employees for service accrued subsequent to participation in the MERS. Following the enrollment in MERS of the initial hires, and every month thereafter, a Form CO-923 will be generated by the MERS Unit and forwarded to the municipality for completion. The fully completed Form CO-923 and required contribution payments should be returned to the MERS Unit within 30 days of receipt of the Form CO-923. Please note that interest charges will be assessed if the form and payment are not received by the MERS Unit within 60 days of the municipality's receipt of the Form CO-923.

Retirement Application Forms - Must Be Completed (or Completed in Part) by Employers and forwarded to CMERS by the Employer

The CMERS unit has developed new retirement application, option factor and spousal waiver forms to be used by CMERS employers. These new forms were developed to correspond with statutory changes that have occurred since the old forms were first printed and to provide additional information to MERS retirees. All of these forms are "fillable" on the system and must be used in connection with all retirement applications effective January 1, 2010. The "new" forms are not being printed in "hard copies" - if an employer needs a hard copy it will need to print the form off from the website. These new, revised retirement forms are available on the Office of the State Comptroller website at the following link: http://www.osc.ct.gov/rbsd/forms.html

Retirement Application Forms

APPLICATION FOR MERS RETIREMENT BENEFITS (PART B)
PDF format WORD format
APPLICATION FOR MERS RETIREMENT BENEFITS (PART A)
PDF format WORD format
APPLICATION ACKNOWLEDGEMENT FORM - SERVICE CONNECTED DISABILITY RETIREMENT
PDF format WORD format
APPLICATION FOR DISABILITY RETIREMENT - MEMBER'S STATEMENT
  WORD format
APPLICATION FOR DISABILITY RETIREMENT - PHYSICIAN'S STATEMENT
PDF format WORD format
APPLICATION FOR DISABILITY RETIREMENT - EMPLOYER'S STATEMENT
PDF format WORD format

This form must be prepared by the municipality when a qualified member wishes to receive a monthly retirement pension benefit from the MERS. The municipality must complete both the front and back of the application and the member must insert the effective date of retirement, sign and date the form in the spaces provided on the reverse side of the application. The municipality must also certify that all the information on the application is correct by having an authorized individual sign and date the form on the last line on the back of the application. The authorized individual should also indicate their title and telephone number in the spaces provided on the form. The completed form must be forwarded to the MERS Unit by the municipality or employer along with the other required paperwork listed on the front of the application.

Option Payment Election Forms

One of the following Option Election forms must be completed by a MERS member when they apply to retire. The retiring member should review the option choices carefully and select the one that will provide retirement income in the form best suited to their personal needs; the member must make this election with care, as the option cannot be changed after retirement. The option forms must be signed and dated by both the member and a witness.

MERS INCOME PAYMENT ELECTION FORM - Option A
PDF format WORD format
MERS INCOME PAYMENT ELECTION FORM - Option B
PDF format WORD format
MERS INCOME PAYMENT ELECTION FORM - Option C
PDF format WORD format
MERS INCOME PAYMENT ELECTION FORM - Option D
PDF format WORD format

Spouse Waiver and Marital Certification Forms

If a member has been married more than one year prior to retirement, his or her spouse's consent will be required on the Spousal Waiver form if the member does not provide a lifetime guaranteed payment (Option A or Option B (50% or 100%)) for that spouse.

Single members and members who have been married less than one year prior to retirement and does not provide a lifetime guaranteed payment (Option A or Option B (50% or 100%) for that spouse must fill out the Certification of Marital Status form.

One of the two forms below must be completed by members at the time of retirement in accordance with the instructions on the form. The only CMERS member who does not have to submit one of these two forms is a married member who has chosen payment (Option A or Option B (50% or 100%)) and has listed that spouse as a contingent annuitant. Signatures to the form must be properly notarized and/or witnessed.

SPOUSE WAIVER OF MONTHLY SURVIVOR BENEFIT (MERS)
PDF format WORD format
CERTIFICATION OF MARITAL STATUS (MERS)
PDF format WORD format

Post Termination or Post Retirement Forms - Primarily for Members and Retirees

Form CO-1212, "Application for Refund of Retirement Contributions for Non-vested members"

This form should be provided to members who terminate their municipal employment and elect to take a lump-sum refund of their contributions. The form must be completed by the member and the municipality and forwarded to the MERS Unit. Important note: Members relinquish any and all retirement benefit to which they may be entitled if they receive a refund of their contributions.

Form CO-675-1, "Application for Refund of Municipal Retirement Contributions - of Deceased Member"

CO-1068 Direct Deposit Authorization Form

CMERS strongly urge retirees and annuitants to have their monthly benefit checks deposited directly into their bank accounts. If an individual other than the retiree or annuitant is signing and filing this form with CMERS, then a properly notarized Power of Attorney or other legal instrument must accompany the filing. Additionally, in such a case, CMERS reserves the right to obtain additional information as it deems appropriate.

CO-931 Change of Beneficiary Form

This form should be filled out by both members and retirees who wish to change their beneficiary. Please note that if a married member or retiree wishes to designate someone other than a spouse as a beneficiary, a spousal waiver may be required and should accompany this form.

CO-1210 Retiree/Annuitant Address Change Form

This form needs to be filled out by retirees as well as their beneficiaries and contingent annuitants (if applicable) if they move and intend to stay at the new address more than ninety (90) days. This requirement is necessary even if the retiree or annuitant leaves out of state for only a portion of the calendar year. If an individual other than the retiree or annuitant is signing and filing this form with CMERS, then a properly notarized Power of Attorney or other legal instrument must accompany the filing.

W-4P (Tax Withholding Form)

Form W-4P is for U.S. citizens, resident aliens, or their estates who are recipients of pensions, annuities (including commercial annuities), and certain other deferred compensation. Use Form W-4P to tell payers the correct amount of federal income tax to withhold from your payment(s). You also may use Form W-4P to choose (a) not to have any federal income tax withheld from the payment (except for eligible rollover distributions, or payments to U.S. citizens delivered outside the United States or its possessions) or (b) to have an additional amount of tax withheld.

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