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ELECTION UNDER THE 2003 EARLY RETIREMENT INCENTIVE PROGRAM AND DEFERRAL OF THE EFFECTIVE DATE OF RETIREMENT: EXCLUSIVELY FOR ELIGIBLE EMPLOYEES SPECIFIED IN SPECIAL ACT NO. 03-2. |
STATE OF CONNECTICUT OFFICE OF THE STATE COMPTROLLER RETIREMENT & BENEFIT SERVICES DIVISION 55 ELM STREET HARTFORD, CT 06106-1775 |
| CO-1101A REV 05/03 |
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NAME OF SERS MEMBER (APPLICANT) |
EMPLOYEE NUMBER |
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TITLE OF POSITION |
EMPLOYING AGENCY |
PART I: RETIREMENT ELECTION
(TO BE COMPLETED BY THE SERS MEMBER)
I HEREBY ELECT AS A MEMBER OF THE STATE EMPLOYEES RETIREMENT SYSTEM TO RETIRE EFFECTIVE NO LATER THAN JUNE 1,2003 UNDER THE 2003 EARLY RETIREMENT INCENTIVE PROGRAM. I UNDERSTAND THAT IF THIS ELECTION FORM IS NOT ON FILE IN THE RETIREMENT & BENEFIT SERVICES DIVISION ON OR BEFORE MAY 30, 2003, I WILL BE INELIGIBLE FOR THE THREE INCENTIVE YEARS OF CREDIT PROVIDED BY THE PROGRAM. IN ADDITION, I UNDERSTAND THAT I MUST MEET THE ELIGIBILITY REQUIREMENTS SET FORTH BY THE PROGRAM BEFORE JUNE 1, 2003.
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SIGNATURE OF SERS MEMBER (APPLICANT) |
DATE |
PART II: DEFERRAL OF EFFECTIVE DATE
(TO BE COMPLETED BY AUTHORIZED AGENCY PERSONNEL)
| THE EFFECTIVE DATE OF RETIREMENT FOR THE ABOVE REFERENCED EMPLOYEE, AN EMPLOYEE AT THIS AGENCY, IS BEING DEFERRED TO | |
| _____________________________ | IT IS UNDERSTOOD THAT ALL PAPERWORK ASSOCIATED WITH A RETIREMENT |
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ENTER AN EFFECTIVE DATE OF RETIREMENT NO LATER THAN JUNE 1,2004. |
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| APPLICATION UNDER THE EARLY RETIREMENT INCENTIVE PROGRAM MUST BE RECEIVED BY THE RETIREMENT & BENEFIT SERVICES DIVISION PRIOR TO THE MEMBER'S DEFERRED EFFECTIVE DATE OF RETIREMENT. | |
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AUTHORIZED AGENCY SIGNATURE |
TITLE |
DATE |
AUTHORITY FOR DEFERRAL AS OUTLINED IN RETIREMENT & BENEFIT SERVICES DIVISION MEMORANDUM DATED MAY 2, 2003 MUST BE ATTACHED TO THIS FORM.
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