AMOUNT DUE:  $	     
     
     
     
	Lump sum, paid
     

     
     
     
     
     
	Missed Contributions:
From:	     
To:	     
	Erroneous Deduction Code:
From:	     
To:	     
	Erroneous Refund:
Date paid	     
Amount  $	     
	Other:  Explain
     
EMPLOYEE INFORMATION
AGENCY SECTION

HEALTHCARE POLICY & BENEFIT SERVICES DIVISION

RETIREE HEALTH FUND PAYMENT ADJUSTMENT

FORM MUST BE
COMPLETED BY AGENCY
HUMAN RESOURCES/
PAYROLL OFFICE

CO-1328 9/2014

Part I - General Information

This form should be used to authorize additional payments to the Retiree Health Fund due to missed contributions, use of an incorrect deduction code or similar reasons, such as erroneous issuance of a refund.  (All adjustments are implemented by using the ADJOPE deduction code.)

Name (last, first, middle initial)

Former name (if applicable)

Employee Number

Street Address

Department ID

Job Record Number

City, State, Zip Code

Date of Hire/Rehire

Date of Birth

Employee's personal e-mail

Office Telephone No.

Home Telephone No.

Name & Address of Employing Agency

ADJOPE START DATE

/

/

ADJOPE END DATE

installments of $

per pay period

/

/

Reason for Payment:

EMPLOYEE ACKNOWLEDGEMENT:
I authorize the deduction of the above amount from my paycheck until the amount due to the Retiree Health Fund is paid in full.  I understand that this payment is in addition to my regular contribution to the Retiree Health Fund and that the end date shown above will be extended if I miss one or more installments for any reason.

EMPLOYEE SIGNATURE

DATE

AGENCY CERTIFICATION: I hereby certify that all the information on this application has been verified and is correct.

AUTHORIZED AGENCY SIGNATURE

TITLE

DATE

AGENCY CONTACT (PRINT NAME)

AGENCY CONTACT NUMBER

MAKE A COPY FOR YOUR RECORDS
Return to OSC, Healthcare Policy & Benefit Services Division
55 Elm Street, Hartford, CT 06106
E-mail: Osc.opeb@ct.gov