DESIGNATION OF RETIREMENT PLAN ELECTION
Higher Education Employment Only
CO-931h Rev. 9/2017
STATE OF CONNECTICUT
OFFICE OF THE STATE COMPTROLLER
RETIREMENT SERVICES DIVISION
CHECK TYPES OF ACTIONS BEING SUBMITTED ON THIS FORM
I. EMPLOYEE PERSONAL INFORMATION
LAST NAME
EMPLOYEE NO.
SOCIAL SECURITY NUMBER
DATE OF BIRTH
GENDER MALE FEMALE
ADDRESS (Street No., Name) (City, State, Zip Code)
MARITAL STATUS MARRIED
SINGLE
DATE OF MARRIAGE NAME OF SPOUSE
II. EMPLOYMENT INFORMATION
EMPLOYING AGENCY RECORD NUMBER AGENCY ADDRESS
EMPLOYMENT DATE/EFFECTIVE DATE BARG UNIT CORE-CT JOB CODE EMPLOYMENT STATUS
Full-time Part-time
TYPE STATUS
Permanent
Temporary
Durational
Intermittent
IS EMPLOYEE CURRENTLY EMPLOYED WITH ANOTHER STATE AGENCY?
YES
NO
If YES, provide Agency Name
HAS EMPLOYEE WORKED FOR THE STATE BEFORE? YES
NO
If YES, provide Agency Name and termination date
NEW
EMPLOYEE
RE-EMPLOYED
MULTIPLE
EMPLOYMENT
General Instructions: This form is to be completed for all employees hired in an institution of higher education or the board of higher education
central office only.
As a condition of employment with the State of Connecticut, all faculty and staff members must participate in a retirement plan with the exception
of part-time Adjunct Faculty members. Part-time Adjunct Faculty members may elect to waive retirement plan membership.
Classified employees in higher education automatically become members of the State Employees Retirement System (SERS).
Unclassified employees must make a one-time irrevocable election of retirement plan membership. Serious consideration must be given
to the election of a retirement plan, as it is an irrevocable decision. Election must be made by the first day of employment. The
proper retirement plan contributions must be deducted from the employee's first paycheck.
Special note: If you elect the ARP, Hybrid or TRS and are subsequently employed in a position ineligible for participation in these plans, you will
automatically begin participation in SERS.
See page 2 for retirement plan election choices.
III. RETIREMENT INFORMATION
Page 1 of 2
AGENCY
TRANSFER
This form must be completed by the employing agency in conjunction with the employee, signed by both the employee and agency staff in
Section IV and returned to the Retirement Services Division as soon as possible following the individual's employment date or effective date of
any change.
DO YOU HAVE A PENSION DIVISION ORDER ("QDRO") AS A RESULT OF DIVORCE/LEGAL SEPARATION?
IF YES, HAS THE ORDER BEEN SUBMITTED TO AND ACCEPTED BY THE RETIREMENT SERVICES DIVISION?
YES
YES
NO
NO
FIRST NAME
M.I.
TRANSFER TO OR FROM
HAZARDOUS DUTY
CHANGE IN RETIREMENT
ELIGIBILITY STATUS
Central Connecticut State University
1615 Stanley Street, New Britain, CT 06050
