State of Connecticut Office of the State Comptroller Attachment to MEMORANDUM NO. 2003-24

Attachment to MEMORANDUM NO. 2003-24

DEFERRED PAYMENT OF ACCRUED VACATION AND SICK LEAVE FOR PARTICIPANTS OF THE 2003 EARLY RETIREMENT INCENTIVE PROGRAM

ONE COPY OF THIS FORM SHOULD BE DELIVERED TO EACH OF THE FOLLOWING : THE STATE COMPTROLLER PAYROLL SERVICES DIVISION, 55 ELM STREET, HARTFORD, CONNECTICUT, 06106, THE STATE COMPTROLLER RETIREMENT AND BENEFITS SERVICES DIVISION, 55 ELM STREET, HARTFORD, CONNECTICUT, 06106, AND RETAINED AT THE AGENCY.
AGENCY NAME				DEPARTMENT		PAGE	OF
FUND SOURCE FUND/AGENCY/SID*	EMPLOYEE NAME	EMPLOYEE NUMBER	EMPLOYEE SOC. SEC. NUMBER	AMOUNT OF ACCRUAL INSTALLMENT
FUND SOURCE FUND/AGENCY/SID*	EMPLOYEE NAME	EMPLOYEE NUMBER	EMPLOYEE SOC. SEC. NUMBER	INSTALLMENT DATE	7/1/2005	7/1/2006	7/1/2007
				CHECK DATE	6/24/2005	6/23/2006	6/22/2007
				Total Vacation Due $ /3
				Total Sick Due $ /3
				Total Vacation Due $ /3
				Total Sick Due $ /3
				Total Vacation Due $ /3
				Total Sick Due $ /3


CERTIFICATION OF AGENCY REPRESENTATIVE
* INDICATE ANY ANTICIPATED FUNDING PROBLEMS ON AN ATTACHED PAGE