WAIVER OF RETIREMENT PLAN PARTICIPATION
Connecticut State University Part-time Employees
Rev. 5-1-08
Note: Retired members of the State Employees Retirement System, the Alternate Retirement Program, and the Teachers Retirement System are subject to reemployment limitations and must complete Form CO-931, "Designation of Retirement System-Tier-Plan-Beneficiary". The following waiver provision does not apply to retired members.
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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