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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:
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users to read any document in Adobe PDF format. The tool converts PDF
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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 07/16 |
N/A |
RETIREMENT - DIRECT DEPOSIT AUTHORIZATION AND INPUT FORM
PDF format |
134 KB |
|
| 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:
April 21, 2021
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