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for a full list of Comptroller's forms, click here
Comptroller's Retirement Services Division Forms
For the PDF files included in this index:
- Access.Adobe.Com is a tool that allows blind and visually impaired
users to read any document in Adobe PDF format. The tool converts PDF
documents into simple HTML or ASCII text, which can then be read by a number
of common screen reading programs that synthesize the HTML as audible
speech.
- There are three ways to use Access Adobe:
- By form submission,
- By email or
- By an Acrobat for Windows plug in.
- Please go to: http://access.adobe.com
for more information.
Retirement Services Division Forms are continually being updated and
redesigned. We welcome your suggestions as to format or wording. Please send
your comments to osc.rsd@ct.gov
Most of these forms have been designed to allow you to complete the form
online and then print the form for any necessary signatures. You may also
print a blank copy of any of these forms to be completed manually.
| Accounting Unit |
FORM
NUMBER |
CATALOG
NUMBER |
FORM NAME |
FILE
SIZE |
SOURCE DOCUMENT |
CO-215
Rev 08/15 |
N/A |
SEBAC 2011 OPTION TO RETAIN GRANDFATHERED NORMAL RETIREMENT DATE
PDF format |
141 KB |
|
| FAQS |
CO-216
2/2019 |
N/A |
SEBAC 2011 Option to Retain Grandfathered
Normal Retirement Date PDF Format |
18 KB |
|
CO-628
Rev 12/19 |
N/A |
APPLICATION FOR REFUND OF RETIREMENT
CONTRIBUTIONS - SERS, Tier I Members Only and Probate Judges
& Employees Retirement System Members -
WORD format PDF
format |
271 KB |
|
CO-628a
Rev 12/19 |
N/A |
APPLICATION FOR REFUND OF RETIREMENT
CONTRIBUTIONS -Tier II Hazardous Duty Members Only
PDF
format |
308 KB |
|
CO-628b
Rev 12/19 |
N/A |
APPLICATION FOR REFUND OF RETIREMENT
CONTRIBUTIONS - Tier IIA Members - Non Vested Only
PDF
format |
281 KB |
|
CO-628c
Rev 12/19 |
N/A |
APPLICATION FOR REFUND OF HAZARDOUS DUTY RETIREMENT
CONTRIBUTIONS Tier I & Tier IIA
PDF
format |
254 KB |
|
CO-628d
Rev 12/19 |
N/A |
APPLICATION FOR REFUND OF RETIREMENT
CONTRIBUTIONS - Tier III Members - Non Vested Only
PDF format |
265 KB |
|
CO-628f
Rev 12/19 |
N/A |
APPLICATION FOR REFUND OF RETIREMENT
CONTRIBUTIONS
State Employees Retirement System, Hybrid Plan Members - Non Vested Only
PDF format |
|
|
| Audit Unit |
FORM
NUMBER |
CATALOG
NUMBER |
FORM NAME |
FILE
SIZE |
SOURCE DOCUMENT |
CO-649
Rev 8/15 |
N/A |
DISABILITY RETIREMENT APPLICATION MEDICAL REPORT
PDF format |
123KB |
|
CO-898
Rev 12//19 |
N/A |
APPLICATION FOR RETIREMENT BENEFITS
PDF format |
567 KB |
|
CO-899
Rev 12/19 |
N/A |
INCOME PAYMENT
ELECTION FORM - OPTION A
PDF
format |
|
|
CO-900
Rev 01/20 |
N/A |
INCOME PAYMENT ELECTION FORM - OPTION B
- 50% OR 100% SURVIVOR
PDF format |
164 KB |
|
CO-901
Rev 12/19 |
N/A |
INCOME PAYMENT ELECTION FORM - OPTION C
- 10 TO 20 YEARS PERIOD CERTAIN
PDF format |
165 KB |
|
CO-902
Rev 12/19 |
N/A |
INCOME PAYMENT ELECTION FORM - OPTION D
- STRAIGHT LIFE ANNUITY
PDF format |
132 KB |
|
CO-1047
Rev 09/15 |
N/A |
SPOUSE WAIVER OF MONTHLY SURVIVOR BENEFITS
PDF Format |
179 KB |
|
CO-1068
Rev 10/21
|
N/A |
RETIREMENT - DIRECT DEPOSIT AUTHORIZATION AND INPUT FORM
PDF format
Additional Info on how to complete this form |
134 KB |
|
Rev 3/22 |
N/A |
AKA NAME AFFIDAVIT
PDF format
Additional Info
For purposes of birth certificate, if the name is different, court documents can be provided as proof of a name change or the person can complete this form.
|
123KB |
|
Rev 3/22 |
N/A |
PROOF OF BIRTH AFFIDAVIT
PDF format
Additional Info
For purposes of birth certificate, persons born outside of the US who do not have a birth certificate must complete this form.
|
74KB |
|
Rev 3/22 |
N/A |
PROOF OF MARRIAGE AFFIDAVIT
PDF format
Additional Info
For purposes of a marriage license, individuals married outside of the US who do not have a marriage certificate must complete this form. Please note: for proof of marriage, we require a government issued marriage license/certificate. A religious or ceremonial record is not sufficient. Individuals who are unable to provide a government issued marriage license/certificate, must also complete this form.
|
55KB |
|
| Customer Service Center |
FORM
NUMBER |
CATALOG
NUMBER |
FORM NAME |
FILE
SIZE |
SOURCE DOCUMENT |
| CO-931(T4S) |
NA |
DESIGNATION OF RETIREMENT PLAN ELECTION
Tier IV SDE Substitute
Instructors first hired or rehired on or after 7/31/17 -
PDF format |
|
|
CO-931
Rev 12/19 |
NA |
DESIGNATION OF
RETIREMENT PLAN ELECTION -
PDF format
|
256 Kb |
|
CO-931
Rev 09/15 |
NA |
MUNICIPAL EMPLOYEE RETIREMENT SYSTEM - DESIGNATION OF BENEFICIARY
PDF format
|
256 Kb |
|
CO-931h
Rev 12-19 |
N/A |
DESIGNATION OF
RETIREMENT PLAN ELECTION - HIGHER EDUCATION
PDF format
|
71 KB |
|
CO-999
Rev 6-18 |
N/A |
DESIGNATION OF RETIREMENT PLAN BENEFICIARY
PDF format |
|
|
CO-1208
Rev12/19 |
N/A |
TEMPORARY POST RETIREMENT REEMPLOYMENT
WORD format PDF
format |
120 Kb |
|
| Legal Documents |
FORM
NUMBER |
CATALOG
NUMBER |
FORM NAME |
FILE
SIZE |
SOURCE DOCUMENT |
Form 900
Rev 09/15 |
N/A |
Financial Affidavit
PDF format |
1,514 KB |
|
CO-1049
Rev 8/15 |
N/A |
LIMITED DURABLE POWER OF ATTORNEY (LDPOA) - PRE RETIREMENT
PDF format |
241 KB |
|
CO-1049A
Rev 12/19 |
N/A |
LIMITED DURABLE POWER OF ATTORNEY (LDPOA) - POST RETIREMENT
PDF format |
227 KB |
|
CO-1060
Rev 8/15 |
N/A |
FINANCIAL AFFIDAVIT FORM
PDF format |
639 KB |
|
| Miscellaneous Unit |
FORM
NUMBER |
CATALOG
NUMBER |
FORM NAME |
FILE
SIZE |
SOURCE DOCUMENT |
CO-898a
Rev 12/19 |
N/A |
APPLICATION FOR ALTERNATE RETIREMENT PROGRAM RETIREMENT BENEFITS
PDF format |
325 KB |
|
CO-898P
Rev 12/19 |
N/A |
APPLICATION FOR RETIREMENT BENEFITS
PDF format |
271 KB |
|
CO-899P
Rev 12/19 |
N/A |
INCOME PAYMENT ELECTION FORM - OPTION A
- 50% SPOUSE
PDF format |
152 KB |
|
CO-900P
Rev 01/20 |
N/A |
INCOME PAYMENT ELECTION FORM - OPTION B
- 50% OR 100% SURVIVOR
PDF format |
162 KB |
|
CO-901P
Rev 12/19 |
N/A |
INCOME PAYMENT ELECTION FORM - OPTION C
- 10 TO 20 YEARS PERIOD CERTAIN
PDF format |
165 KB |
|
CO-902P
Rev12/19 |
N/A |
INCOME PAYMENT ELECTION FORM - OPTION D
- STRAIGHT LIFE ANNUITY
PDF format |
133 KB |
|
CO-931J
Rev 12/19 |
N/A |
DESIGNATION OF RETIREMENT SYSTEM-TIER-PLAN-BENEFICIARY
JUDICIAL BRANCH
PDF format |
295 KB |
Retirement Services Division Memo 2012-01
Dated January 3, 2012 |
CO-931P
Rev 12/19 |
N/A |
DESIGNATION OF RETIREMENT SYSTEM-TIER-PLAN-BENEFICIARY
PROBATE JUDGES AND EMPLOYEES
PDF format |
294 KB |
|
CO-995
Rev 9/15 |
N/A |
APPLICATION FOR USE OF ENCUMBERED FUNDS FOR HYBRID PLAN TRANSFER
PDF format |
194 KB |
|
CO-996
Rev 9/15 |
N/A |
SEBAC 2011 Option to Transfer from the Alternate
Retirement Program to the State Employees Retirement System Hybrid Plan -
Prospective Only
PDF format |
137 KB |
|
CO-1047P
Rev 8/15 |
N/A |
SPOUSE WAIVER OF MONTHLY SURVIVOR BENEFITS
PDF format |
148 KB |
|
| Purchasing Unit |
FORM
NUMBER |
CATALOG
NUMBER |
FORM NAME |
FILE
SIZE |
SOURCE DOCUMENT |
CO-896
Rev 12/19 |
N/A |
RETIREMENT CREDIT PURCHASE REQUEST - TIER 1 -
PDF format |
194Kb |
|
CO-922
Rev 12/19 |
N/A |
RETIREMENT CREDIT REQUEST FORM - TIER II MEMBERS ONLY
PDF format |
164Kb |
|
CO-988
Rev 12/19 |
N/A |
Request for Retirement Credit for Qualifying Leaves without Pay (LAW)
FOR TIER II NON-HAZARDOUS DUTY MEMBERS ONLY
PDF format |
|
|
CO-989
Rev 12/19 |
N/A |
RETIREMENT CREDIT RESTORATION REQUEST - REEMPLOYED TIER II HAZARDOUS
DUTY MEMBERS ONLY
PDF format |
157Kb |
|
CO-990
Rev 12/19 |
N/A |
Request For Retirement Credit for Qualifying Leaves Without Pay (LAW)
- FOR TIER II HAZARDOUS DUTY MEMBERS ONLY
PDF format |
145Kb |
|
CO-991
Rev 8/15 |
N/A |
RETIREMENT CREDIT PURCHASE REQUEST- PRIOR MISC SERVICE FOR TIER III AND
HYBRID MEMBERS ONLY
PDF format |
206Kb |
|
CO-992
Rev 12/19 |
N/A |
RETIREMENT CREDIT RESTORATION REQUEST -
REEMPLOYED TIER III AND HYBRID MEMBERS ONLY
PDF format |
213Kb
|
|
CO-993
Rev 8/15 |
N/A |
RETIREMENT CREDIT PURCHASE REQUEST FOR QUALIFYING LEAVES WITHOUT PAY - TIER III
AND HYBRID MEMBERS ONLY
PDF format |
209Kb
|
|
CO-1088
Rev 12/19 |
N/A |
RETIREMENT CREDIT PURCHASE REQUEST- PRIOR MISC SERVICE
PDF format |
161 Kb |
Purchasing Unit
Retirement Division Tier 2A Memorandum |
CO-1089
Rev 12/19 |
N/A |
RETIREMENT CREDIT RESTORATION REQUEST
PDF format |
164 Kb
|
Purchasing Unit
Retirement Division Tier 2A Memorandum |
CO-1090
Rev 12/19 |
N/A |
RETIREMENT CREDIT PURCHASE REQUEST- LEAVES WITHOUT PAY
PDF format |
148 Kb
|
Purchasing Unit
Retirement Division Tier 2A Memorandum |
| Municipal Employees Retirement
System (MERS) Unit |
FORM
NUMBER |
CATALOG
NUMBER |
FORM NAME |
FILE
SIZE |
SOURCE DOCUMENT |
CO-649
Rev 8/15 |
N/A |
DISABILITY RETIREMENT APPLICATION MEDICAL REPORT
PDF format |
123KB |
|
CO-923
Rev 08/15 |
N/A |
MONTHLY REPORT
OF EMPLOYEE AND MUNICIPAL CONTRIBUTIONS
PDF format |
312 KB |
|
CO-1074
Rev 08/15 |
N/A |
ROSTER OF EMPLOYEES
PDF format |
331 KB |
|
CO-1200
Rev 12/19 |
N/A |
APPLICATION FOR MERS RETIREMENT BENEFITS (PART B)
PDF format |
263 KB |
MERS Unit |
CO-1201
Rev 12/19 |
N/A |
MERS INCOME PAYMENT ELECTION FORM - Option A
PDF format |
148 KB |
MERS Unit |
CO-1202
Rev 12/19 |
N/A |
MERS INCOME PAYMENT ELECTION FORM - Option B
PDF format |
166 KB |
MERS Unit |
CO-1203
Rev 12/19 |
N/A |
MERS INCOME PAYMENT ELECTION FORM - Option C
PDF format |
168 KB |
MERS Unit |
CO-1204
Rev 08/15 |
N/A |
MERS INCOME PAYMENT ELECTION FORM - Option D
PDF format |
133 KB |
MERS Unit |
CO-1205
Rev 08/15 |
N/A |
SPOUSE WAIVER OF MONTHLY SURVIVOR BENEFIT (MERS)
PDF format |
155KB |
MERS Unit |
CO-1206
Rev 08/15 |
N/A |
CERTIFICATION OF MARITAL STATUS (MERS)
PDF format |
145 KB |
MERS Unit |
CO-1207
Rev12/19 |
N/A |
APPLICATION FOR MERS RETIREMENT BENEFITS (PART A)
PDF format |
285KB |
MERS Unit |
CO-1209
Rev 12/19 |
N/A |
ACKNOWLEDGEMENT FORM - SCD (MERS)
PDF format |
131 KB |
MERS Unit |
CO-1210
Rev 09/15 |
N/A |
RETIREE/ANNUITY ADDRESS CHANGE FORM (MERS)
PDF format |
89 Kb |
MERS Unit |
CO-1212
Rev 12/19 |
N/A |
MERS APPLICATION FOR REFUND OF RETIREMENT CONTRIBUTIONS FOR
NON-VESTED MEMBERS
PDF format |
277 Kb |
MERS Unit |
This page was last updated on:
October 26, 2021
|
