Fillable Form CO-999 DESIGNATION OF RETIREMENT PLAN BENEFICIARY connecticut

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Form CO-999 DESIGNATION OF RETIREMENT PLAN BENEFICIARY connecticut

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Country of origin: US
File type: PDF

U.S.A. forms for Central Connecticut State University

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DESIGNATION OF RETIREMENT PLAN BENEFICIARY
CO-999 9/2017
STATE OF CONNECTICUT
OFFICE OF THE STATE COMPTROLLER
RETIREMENT SERVICES DIVISION
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
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.
NAME OF BENEFICIARY
SOCIAL SECURITY
NUMBER
ADDRESS (Street No., Name)
RELATIONSHIP
(City, State, Zip Code) PERCENT DATE OF BIRTH
NAME OF BENEFICIARY
ADDRESS (Street No., Name)
RELATIONSHIP
(City, State, Zip Code) PERCENT DATE OF BIRTH
ADDRESS (Street No., Name) RELATIONSHIP
(City, State, Zip Code) PERCENT DATE OF BIRTH
NAME OF BENEFICIARY
ADDRESS (Street No., Name)
RELATIONSHIP
(City, State, Zip Code) PERCENT DATE OF BIRTH
NAME OF BENEFICIARY
II. BENEFICIARY DESIGNATION
Primary beneficiary(ies) must equal 100%. Contingent beneficiary(ies) must equal 100%. Please use whole percentages. If there are more than (4)
beneficiaries designated, check the box to the right and attach an additional CO-999 form listing additional beneficiaries.
CONTINGENT
CONTINGENT CONTINGENT
SOCIAL SECURITY
NUMBER
SOCIAL SECURITY
NUMBER
SOCIAL SECURITY
NUMBER
Last Name First Name M.I. Last Name First Name M.I.
Last Name First Name M.I. Last Name First Name M.I.
PRIMARY
PRIMARY
PRIMARY
PRIMARY
EMPLOYEE'S SIGNATURE
DATE
AUTHORIZED AGENCY SIGNATURE (& TITLE)
PHONE DATE
Forward completed form to: Retirement Services Division, Customer Service Center, 55 Elm Street, Hartford, CT 06106. Agency should retain one copy and
provide one copy to employee.
III. MEMBER'S STATEMENT
I hereby revoke all previous appointments of beneficiaries made by me, if any, and designate the person(s) named above as beneficiary(ies)
such person(s) to receive upon my death any and all sums due me from the Retirement System of which I am a member. This designation
shall remain in effect unless I subsequently change it by written notice to the Retirement Services Division.
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Form CO-999 DESIGNATION OF RETIREMENT PLAN BENEFICIARY connecticut

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Completed 6 December 2019

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