WAIVER OF RETIREMENT PLAN PARTICIPATION
Connecticut State University Part-time Employees
Rev. 3-1-08
Part-time employees covered by the collective bargaining agreement between
the State and the Connecticut State University - American Association of
University Professors, Inc. (CSU-AAUP/BOT) contract must participate in a
retirement plan unless they irrevocably waive retirement plan membership for
this and any subsequent part-time employment with the agency named below or with
the Board of Governors of Higher Education or any other of its constituent
units. If you are covered by this contract and wish to irrevocably waive your
right to join a pension plan, please complete the following:
| _______________________________ | _________________ | ____________________ |
| Employee Name (Type or Print) | Employee Number | Social Security Number |
| _______________________________ | _________________ | ____________________ |
| Agency Name | Date of Employment | Bargaining Unit |
EMPLOYEE'S STATEMENT: I hereby irrevocably waive my right to membership in
a retirement plan for this and any subsequent part-time employment with this
agency or the Board of Governors of Higher Education or any other of its
constituent units within the State of Connecticut.
| _______________________________________ | ___________________ |
| Employee's Signature | Date |
| _______________________________________ | ___________________ | _____________ |
| Authorized Agency Signature, Title | Date | Phone Number |
Forward original to:
Office of the State Comptroller
Retirement & Benefit Services Division
Data Base Unit
55 Elm Street, Hartford, CT 06016.
Copies to agency and employee.
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