State of Connecticut Office of the State Comptroller RETIREMENT CREDIT FOR LAYOFF

State of Connecticut Office of the State Comptroller RETIREMENT CREDIT FOR LAYOFF - PUBLIC ACT NO. 03-2 Attachment B

ATTACHMENT B

New 03-01-06

Employee Name:	Employee No.:
Address:	SS #:

State Employees Retirement System
Retirement Plan Membership:

Lay-Off Information *

Date:
Agency:
Position:
Salary:

Reemployment Information

Date:
Agency:
Position:
Salary:

_______________________________________	_________________
Employee Signature	Date

_______________________________________	_________________	__________________
Authorized Agency Signature	Date	Telephone Number

*Copy of original lay-off notice must be attached.