TIER I, TIER II HAZARDOUS DUTY & TIER IIA MEMBERS ONLY
REQUEST FOR EXPLANATION OF RETIREMENT CONTRIBUTION ACCOUNT BALANCE
(Please type or print)
EMPLOYEE NAME:
EMPLOYEE NUMBER:
SOCIAL SECURITY NUMBER:
EMPLOYEE ADDRESS: |
Street: |
Town: | |
State, Zip Code: |
SPECIFIC REASON FOR REQUEST:
_______________________________ |
________________ |
Employee Signature | Date |
_______________________________ | ________________ |
Authorized Agency Signature | Date |
SEND TO: | RETIREMENT & BENEFIT SERVICES DIVISION |
OFFICE OF THE STATE COMPTROLLER | |
55 ELM STREET | |
HARTFORD, CT 06106 | |
ATTN: DATA BASE UNIT |
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