Personal Information
Your benefits and personal data have been valued as of: JUNE 30, 2000
nis statement has been based on the following information:
Social Security Number - 123-45-6789
Employee Number - 111111
Date of birth - 6/30/1961
Retirement Plan coverage - TIER 1, PLAN B
Retirement Plan beneficiary(ies) - Life Insurance beneficiary(ies) -
RETBENE FIRST LIFEBENE FIRST
RETBENE SECOND LIFEBENESECOND
If You Have Questions-.
While retirement may be far in the future for most of us, it is a time of life that should be planned for. If you have any questions about any portion of this statement or need more specific information regarding your retirement benefit, see your agency personnel officer. If any of the personal data shown on this statement is incorrect, your agency will provide the forms to correct it. Any changes to your name, address, and beneficiaries will not be made without the proper form.
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Additional Service Credit JOHN B. DOE I 111111 123-45-6789
Listed below is miscellaneous service for which our records indicate you have additional retirement credit. ff any of the information is incorrect or incomplete, tear off the panel and return it directly to the Retirement & Benefit Services Division, 55 Elm Street, Hartford, Connecticut 06106, Attention: Data Base Unit You must forward a copy of the acknowledgement of credit letter with the panel; Tier II non-contributory members may forward a copy of Form CO-922 instead. If you did not retain this documentation, see your agency. Please note: Purchases in progress are not reflected.
Purchase Type Purchase Code From To
Sick/Family/Parental Leave 5-174A 12/04/1987 04/03/1988 SICK LEAVE MONTHS 4
04/04/1988 07/24/1990 SICK LEAVE MONTHS 1
05/23/1990 07/22/1990 SICK LEAVE MONTHS 2
There are certain limited types of additional service credits which may be purchased by Tier I members.
Contact your agency personnel office or the Retirement & Benefit Services Division's Counseling Unit for information.
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