Retirement Services Division Memorandum 2012-10
Attachment - Agency Certification

Return to:   Office of the State Comptroller
   Retirement Services Division
   Attention: Audit Unit
   55 Elm St.
   Hartford, CT 06106


Pursuant to the Hazardous Duty Arbitration Award of August 22, 2012, this former employee had 20 or more years of hazardous duty service as of June 30, 2009 but was unable to take advantage of the RIP due to the interpretation of vacation accruals. The following serves as the basis for our certification of the employee's years and months of hazardous duty service as of June 30, 2009 and their accrual balance of that date.

Agency: ____________________________________________________

Employee Name:_____________________________________________

Employee Number:____________________

Date of Retirement:____________________

Please state service in years, months and days in the space provided below.

*Actual State Hazardous Duty Service on 6/30/2009  _____  -  _____  -  _____ 
(exclude purchased medical leave)
Accrued vacation days on 6/30/2009  _____  -  _____  -  _____ 
Total Hazardous Duty Service on 6/30/2009  _____   -  _____  -  _____ 

* actual state service excludes leaves without pay

Agency statement:

I certify that the information provided herein is accurate and consistent with this former employee's record.

_____________________________    __________________
Authorized Agency    Signature Date
_____________________________    ___________________
Print Name    Phone Number

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