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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@ct.gov

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.

 

Accounting Unit
FORM
NUMBER
CATALOG
NUMBER
FORM NAME FILE
SIZE
SOURCE DOCUMENT
CO-215
Rev  08/15
N/A SEBAC 2011 OPTION TO RETAIN GRANDFATHERED NORMAL RETIREMENT DATE    PDF format 141 KB  
FAQS 
CO-628
Rev 09/15
N/A  APPLICATION FOR REFUND OF RETIREMENT CONTRIBUTIONS - SERS, Tier I Members Only and Probate Judges & Employees Retirement System Members - WORD format   PDF format 271 KB  
CO-628a
Rev 09/15
N/A  APPLICATION FOR REFUND OF RETIREMENT CONTRIBUTIONS -Tier II Hazardous Duty Members Only
PDF format
308 KB  
CO-628b
Rev 09/15
N/A  APPLICATION FOR REFUND OF RETIREMENT CONTRIBUTIONS - Tier IIA Members - Non Vested Only
 PDF format
281 KB  
CO-628c
Rev 09/15
N/A  APPLICATION FOR REFUND OF HAZARDOUS DUTY RETIREMENT CONTRIBUTIONS Tier I & Tier IIA
  PDF format
254 KB  
CO-628d
Rev 09/15
N/A  APPLICATION FOR REFUND OF RETIREMENT CONTRIBUTIONS - Tier III Members - Non Vested Only
  PDF format
265 KB  
CO-628f
Rev 09/15
N/A APPLICATION FOR REFUND OF RETIREMENT CONTRIBUTIONS
State Employees Retirement System, Hybrid Plan Members - Non Vested Only
PDF format
   
 

Audit Unit
FORM
NUMBER
CATALOG
NUMBER
FORM NAME FILE
SIZE
SOURCE DOCUMENT
CO-649
Rev 8/15
N/A DISABILITY RETIREMENT APPLICATION MEDICAL REPORT
PDF format
123KB  
CO-898
Rev 4/16
N/A APPLICATION FOR RETIREMENT BENEFITS
PDF format
567 KB  
CO-899
Rev 07/15
N/A INCOME PAYMENT ELECTION FORM - OPTION A
PDF format
   
CO-900
Rev 11/15
N/A INCOME PAYMENT ELECTION FORM - OPTION B
- 50% OR 100% SURVIVOR
PDF format
164 KB  
CO-901
Rev 08/15
N/A INCOME PAYMENT ELECTION FORM - OPTION C
- 10 TO 20 YEARS PERIOD CERTAIN
PDF format
165 KB  
CO-902
Rev 8/15
N/A INCOME PAYMENT ELECTION FORM - OPTION D - STRAIGHT LIFE ANNUITY
PDF format
132 KB  
CO-1047
Rev 09/15
N/A SPOUSE WAIVER OF MONTHLY SURVIVOR BENEFITS
PDF Format
179 KB  
CO-1068
Rev 07/16
N/A RETIREMENT - DIRECT DEPOSIT AUTHORIZATION AND INPUT FORM
PDF format
134 KB  
 

Customer Service Center
FORM
NUMBER
CATALOG
NUMBER
FORM NAME FILE
SIZE
SOURCE DOCUMENT
CO-931
Rev 07/15
NA DESIGNATION OF RETIREMENT SYSTEM- TIER-PLAN-BENEFICIARY  PDF format
256 Kb  
CO-931
Rev 09/15
NA DESIGNATION OF RETIREMENT SYSTEM- TIER-PLAN-BENEFICIARY -MERS  PDF format
256 Kb  
CO-931h
Rev 05-16
N/A DESIGNATION OF RETIREMENT SYSTEM- TIER-PLAN-BENEFICIARY- HIGHER EDUCATION    PDF format
71 KB  
CO-1208
Rev 09/15
N/A  TEMPORARY POST RETIREMENT REEMPLOYMENT 
WORD format  PDF format
120 Kb  
 
Legal Documents
FORM
NUMBER
CATALOG
NUMBER
FORM NAME FILE
SIZE
SOURCE DOCUMENT
Form 900
Rev 09/15
N/A

Financial Affidavit  PDF format

1,514 KB  
CO-1049
Rev 8/15
N/A LIMITED DURABLE POWER OF ATTORNEY (LDPOA) - PRE RETIREMENT
PDF format
241 KB  
CO-1049A
Rev 8/15
N/A LIMITED DURABLE POWER OF ATTORNEY (LDPOA) - POST RETIREMENT
PDF format
227 KB  
CO-1060
Rev 8/15
N/A FINANCIAL AFFIDAVIT FORM
PDF format
639 KB  
 

 
Miscellaneous Unit
FORM
NUMBER
CATALOG
NUMBER
FORM NAME FILE
SIZE
SOURCE DOCUMENT
CO-898a
Rev 08/15
N/A APPLICATION FOR ALTERNATE RETIREMENT PROGRAM RETIREMENT BENEFITS
 PDF format
325 KB  
CO-898P
Rev 08/15
N/A  APPLICATION FOR RETIREMENT BENEFITS
   PDF format
271 KB  
CO-899P
Rev 08/15
N/A INCOME PAYMENT ELECTION FORM - OPTION A
- 50% SPOUSE
   PDF format
152 KB  
CO-900P
Rev 08/15
N/A INCOME PAYMENT ELECTION FORM - OPTION B
- 50% OR 100% SURVIVOR
  PDF format
162 KB  
CO-901P
Rev 08/15
N/A INCOME PAYMENT ELECTION FORM - OPTION C
- 10 TO 20 YEARS PERIOD CERTAIN
 PDF format
165 KB  
CO-902P
Rev 08/15
N/A INCOME PAYMENT ELECTION FORM - OPTION D
- STRAIGHT LIFE ANNUITY
    PDF format
133 KB  
CO-931J
Rev 8/15
N/A DESIGNATION OF RETIREMENT SYSTEM-TIER-PLAN-BENEFICIARY
JUDICIAL BRANCH
PDF format
295 KB

 Retirement Services Division Memo 2012-01
Dated January 3, 2012

CO-931P
Rev 8/15
N/A DESIGNATION OF RETIREMENT SYSTEM-TIER-PLAN-BENEFICIARY
PROBATE JUDGES AND EMPLOYEES
 PDF format
294 KB  
CO-994
Rev 3/16
N/A SEBAC 2011 Option to transfer from the Alternate Retirement Program to the State Employees Retirement System Hybrid Plan
PDF format
189 KB  
CO-995
Rev 9/15
N/A APPLICATION FOR USE OF ENCUMBERED FUNDS FOR HYBRID PLAN TRANSFER
PDF format
194 KB  
CO-996
Rev 9/15
N/A SEBAC 2011 Option to Transfer from the Alternate Retirement Program to the State Employees Retirement System Hybrid Plan - Prospective Only
PDF format
137 KB  
CO-1047P
Rev 8/15
N/A SPOUSE WAIVER OF MONTHLY SURVIVOR BENEFITS
PDF format
148 KB  
 

 Purchasing Unit
FORM
NUMBER
CATALOG
NUMBER
FORM NAME FILE
SIZE
SOURCE DOCUMENT
CO-896
Rev 08/15
N/A RETIREMENT CREDIT PURCHASE REQUEST - TIER 1 -
PDF format
194Kb  
CO-922
Rev 8/15
N/A RETIREMENT CREDIT REQUEST FORM - TIER II MEMBERS ONLY
PDF format
164Kb  
CO-988
Rev 7/15
N/A Request for Retirement Credit for Qualifying Leaves without Pay (LAW)
FOR TIER II NON-HAZARDOUS DUTY MEMBERS ONLY
  PDF format
   
CO-989
Rev 8/15
N/A RETIREMENT CREDIT RESTORATION REQUEST - REEMPLOYED TIER II HAZARDOUS DUTY MEMBERS ONLY
PDF format
157Kb  
CO-990
Rev 8/15
N/A Request For Retirement Credit for Qualifying Leaves Without Pay (LAW)
- FOR TIER II HAZARDOUS DUTY MEMBERS ONLY
 PDF format
145Kb  
CO-991
Rev 8/15
N/A RETIREMENT CREDIT PURCHASE REQUEST- PRIOR MISC SERVICE FOR TIER III AND HYBRID MEMBERS ONLY
PDF format
206Kb  
CO-992
Rev 8/15
N/A RETIREMENT CREDIT RESTORATION REQUEST -
REEMPLOYED TIER III AND HYBRID MEMBERS ONLY
 PDF format
213Kb
 
CO-993
Rev 8/15
N/A RETIREMENT CREDIT PURCHASE REQUEST FOR QUALIFYING LEAVES WITHOUT PAY - TIER III AND HYBRID MEMBERS ONLY
PDF format
209Kb
 
CO-1088
Rev 8/15
N/A RETIREMENT CREDIT PURCHASE REQUEST- PRIOR MISC SERVICE
PDF format
161 Kb Purchasing Unit
Retirement Division Tier 2A Memorandum 
CO-1089
Rev 8/15
N/A RETIREMENT CREDIT RESTORATION REQUEST
PDF format
164 Kb
Purchasing Unit
Retirement Division Tier 2A Memorandum 
CO-1090
Rev 8/15
N/A RETIREMENT CREDIT PURCHASE REQUEST- LEAVES WITHOUT PAY
PDF format
148 Kb
Purchasing Unit
Retirement Division Tier 2A Memorandum 
 

 
Retirement Payroll Unit
FORM
NUMBER
CATALOG
NUMBER
FORM NAME FILE
SIZE
SOURCE DOCUMENT
CO-1049A
Rev 08/15
N/A LIMITED DURABLE POWER OF ATTORNEY (LDPOA) - POST RETIREMENT
PDF format
227 KB  
CO-1068
Rev 7/16
N/A RETIREMENT - DIRECT DEPOSIT AUTHORIZATION AND INPUT FORM
PDF format
134 KB  
CO-1082
Rev 08/16
N/A RETIREE/ANNUITANT ADDRESS CHANGE FORM
PDF format
16 KB  
  N/A FEDERAL AND CONNECTICUT TAX WITHHOLDING CHANGE FORM    
 CT W4P Withholding Certificate for Pension or Annuity Payments
- http://www.ct.gov/drs/lib/drs/forms/2016withholding/ct-w4p.pdf

Federal W4P Withholding Certificate for Pension or Annuity Payments
- http://www.irs.gov/pub/irs-pdf/fw4p.pdf

 

Municipal Employees Retirement System (MERS) Unit
FORM
NUMBER
CATALOG
NUMBER
FORM NAME FILE
SIZE
SOURCE DOCUMENT
CO-923
Rev 08/15
N/A MONTHLY REPORT OF EMPLOYEE AND MUNICIPAL CONTRIBUTIONS   PDF format 312 KB  
CO-1074
Rev 08/15
N/A ROSTER OF EMPLOYEES
PDF format
331 KB  
CO-1200
Rev 09/15
N/A APPLICATION FOR MERS RETIREMENT BENEFITS (PART B)
PDF format
263 KB MERS Unit
CO-1201
Rev 08/15
N/A MERS INCOME PAYMENT ELECTION FORM - Option A
PDF format
148 KB MERS Unit
CO-1202
Rev 08/15
N/A MERS INCOME PAYMENT ELECTION FORM - Option B
PDF format
166 KB MERS Unit
CO-1203
Rev 08/15
N/A MERS INCOME PAYMENT ELECTION FORM - Option C
PDF format
168 KB MERS Unit
CO-1204
Rev 08/15
N/A MERS INCOME PAYMENT ELECTION FORM - Option D
PDF format
133 KB MERS Unit
CO-1205
Rev 08/15
N/A SPOUSE WAIVER OF MONTHLY SURVIVOR BENEFIT (MERS)
PDF format
155KB MERS Unit
CO-1206
Rev 08/15
N/A CERTIFICATION OF MARITAL STATUS (MERS)
PDF format
145 KB MERS Unit
CO-1207
Rev 08/15
N/A APPLICATION FOR MERS RETIREMENT BENEFITS (PART A)
PDF format
285KB MERS Unit
CO-1209
Rev 09/15
N/A ACKNOWLEDGEMENT FORM - SCD (MERS)
PDF format
131 KB MERS Unit
CO-1210
Rev 09/15
N/A RETIREE/ANNUITY ADDRESS CHANGE FORM (MERS)
 PDF format
89 Kb MERS Unit
CO-1212
Rev 09/15
N/A MERS APPLICATION FOR REFUND OF RETIREMENT CONTRIBUTIONS FOR NON-VESTED MEMBERS
PDF format
277 Kb MERS Unit
CO-1214
Rev 08/15
N/A APPLICATION FOR DISABILITY RETIREMENT -
PHYSICIAN'S STATEMENT
PDF format
171 Kb MERS Unit
CO-1215
Rev 09/15
N/A APPLICATION FOR DISABILITY RETIREMENT -
EMPLOYER'S STATEMENT
PDF format
218 Kb MERS Unit

This page was last updated on: October 04, 2017

 
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