WAIVER OF RETIREMENT PLAN PARTICIPATION
University of Connecticut Special Payroll Lecturers
Rev. 3-1-08
Special Payroll Lecturers covered by the May 26, 2005 agreement between the
University of Connecticut (UConn) and the American Association of University
Professors must participate in the Alternate Retirement Program unless they
irrevocably waive retirement plan membership for this and any subsequent
part-time employment with the University of Connecticut or with the Board of
Governors of Higher Education or any other of its constituent units within 90
days of commencing employment. If you are covered by this agreement 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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