RE-EMPLOYED

     
     
     
     

     

     
     
	NO
	NO

     
     
     
     
     
     
	Part-time

	Temporary
	Intermittent

	If YES, provide Agency Name

     
	If YES, provide Agency Name and termination date

     

DESIGNATION OF RETIREMENT SYSTEM-TIER-PLAN-BENEFICIARY

CO-931 REV. 11/2013

Page 1 of 3

STATE OF CONNECTICUT
OFFICE OF THE STATE COMPTROLLER
RETIREMENT SERVICES DIVISION

General Instructions:  This form is to be completed for all employees hired in any State agency other than institutions of higher education and the board of higher education central office except for those employees of the Judicial Branch who are covered by or are eligible to elect membership in the Judges, Compensation Commissioners and Family Support Magistrates Retirement System, the Public Defenders Retirement System or the State's Attorneys Retirement System.

This form must be completed by the employing agency in conjunction with the employee, each page must be initialed by both the employee and an authorized agency staff member, signed by both the employee and agency staff member in Section V and returned to the Retirement Services Division as soon as possible following the individual's employment date or effective date of any change.

CHECK TYPES OF ACTIONS BEING SUBMITTED ON THIS FORM - THEN CONSULT APPLICABLE INSTRUCTIONS

NEW EMPLOYEE

MULTIPLE EMPLOYMENT

EMPLOYEE NAME AND/OR ADDRESS CHANGE

CHANGE IN BENEFICIARY(IES) NAME AND/OR ADDRESS

AGENCY TRANSFER

CHANGE IN RETIREMENT SYSTEM INFORMATION ONLY

I. EMPLOYEE PERSONAL INFORMATION

EMPLOYEE NAME (Last, First, M.I.)  (1)

EMPLOYEE NO. (2)

SOCIAL SECURITY NUMBER (3)

DATE OF BIRTH (4)

SEX (5)   MALE   FEMALE

EMPLOYEE'S HOME ADDRESS (Street No., Name) (City, State, Zip Code)    (6)

MARITAL STATUS (7)    MARRIED

DATE OF MARRIAGE (8)

NAME OF SPOUSE (9)

SINGLE

DO YOU HAVE A PENSION DIVISION ORDER ("QDRO") AS A RESULT OF DIVORCE/LEGAL SEPARATION?  (10)

YES

IF YES, HAS THE ORDER BEEN SUBMITTED TO AND ACCEPTED BY THE RETIREMENT SERVICES DIVISION?  (11)

YES

II. EMPLOYMENT INFORMATION

EMPLOYING AGENCY (12)

CORE-CT DEPT ID (13)

AGENCY ADDRESS (14)

EMPLOYMENT DATE/EFFECTIVE DATE (15)

BARG UNIT (16)

CORE-CT JOB CODE (17)

EMPLOYMENT STATUS (18)

TYPE STATUS (19)

Full-time

Permanent

Durational

IS EMPLOYEE CURRENTLY EMPLOYED WITH ANOTHER STATE AGENCY? (20)

YES

NO

HAS EMPLOYEE WORKED FOR THE STATE BEFORE? (21)

YES

NO

III. RETIREMENT INFORMATION

A.     New Employees Only (No Prior State Employment):

State Statutes require that each State of Connecticut employee be covered by a retirement system; this is a mandatory requirement.

New state employees automatically become members of the State Employee Retirement System (SERS) Tier III retirement plan except that any teacher in state service but not in higher education required as a condition of their employment to hold an appropriate certificate of qualification issued by the State Board of Education may elect membership in the Teachers Retirement System (TRS) in lieu of membership in SERS Tier III.

State Employees Retirement System (SERS), Tier III

This is a governmental defined benefit plan intended to be qualified under section 401(a) of the Internal Revenue Code.  The employee contribution to this plan is 2% of your salary and contributions are "picked up" by the employer and made on a pre-tax basis.  Should you meet the requirements for receipt of a retirement benefit under this plan, the benefit you receive will be calculated based on a formula which uses the number of years you participated in the plan and the average of your five highest years' salary.  Under the Tier III plan, retirement credit may be granted for some prior employment service including military service and municipal employment.  Restrictions apply.  See the SERS Tier III Summary Plan Description available on the Office of the State Comptroller's website http://www.osc.ct.gov for more details.  

State Teachers' Retirement System (TRS)

This is a governmental defined benefit plan intended to be qualified under section 401(a) of the Internal Revenue Code.  If your employment as a part-time employee is concurrent with employment as a public school teacher, you may elect to have your earnings treated as earnings subject to the Teachers' Retirement System.  The employee contribution is 7.25% of your salary and is "picked up" by the employer and made on a pre-tax basis.  Earnings during summer employment do not apply.  See plan summary for more details.  TRS plan summary information is available on the Teachers Retirement Board's website at http://www.ct.gov/trb/site/default.asp

Your election is irrevocable unless you are subsequently employed in a position not eligible for participation in TRS; under such circumstance you will automatically begin participating in SERS.

Employee's Initials

Agency Staff's Initials

 
	STATE EMPLOYEES RETIREMENT SYSTEM
	TEACHERS RETIREMENT SYSTEM
	INELIGIBLE
	Tier IIA 
	Tier II 
	Tier I 

	NO

	NO

If so, Date of Retirement:	     

     
     

     
     
     
     
     
     
     
     
     
     
     
     

     
     

     
     
     
     
     
     
     
     
     
     
     
     

DESIGNATION OF RETIREMENT SYSTEM-TIER-PLAN-BENEFICIARY

CO-931 REV. 11/2013

STATE OF CONNECTICUT
OFFICE OF THE STATE COMPTROLLER
RETIREMENT SERVICES DIVISION

Page 2 of 3

B.          Employees with Prior State Service (Rehires):

Employees with prior state service must rejoin the retirement tier and plan in which they previously participated unless:

       -     The employee has experienced a permanent break in service.
       -     The employee is hired in a position not eligible for participation in their prior retirement plan.
       -     The employee is hired in a position which affords them the opportunity to elect participation in a retirement plan not previously 
             available  to them.

C.          Employees with Multiple Employment:

Employees who work for another state agency and currently participate in SERS, TRS or for certain employees in higher education, the Alternate Retirement Program (ARP) or the SERS Hybrid Plan, are not entitled to change retirement plan participation as a result of accepting supplemental employment and must remain in the retirement plan to which they are assigned immediately prior to commencing any multiple employment.

Except that employees with full-time positions during which they are members of the TRS must be coded as ineligible for retirement system membership if they are dually employed in a part-time position not includable in TRS.

Employees with full-time positions during which they are members of the ARP or the Hybrid Plan must be coded as ineligible for retirement system membership if they are dually employed in a part-time position not eligible for ARP or the Hybrid Plan membership.

D.          Agency Transfer:

Employees who are members of ARP or the Hybrid Plan and transfer from a state college or university to a non-higher education agency must be enrolled in SERS as of the date of their transfer.

E.          Change in Retirement System Information Only:

SERS membership for employees who transfer from a hazardous duty position to a non-hazardous duty position or from a non-hazardous duty position to a hazardous duty position within the same state agency must be changed effective immediately upon their transfer.

RETIREMENT SYSTEM (22)

Tier III 

Hazardous Duty? 

YES

Are you a retired member of the Teachers' Retirement System?

YES

IV. BENEFICIARY INFORMATION  If there are more than (4) beneficiaries designated, check the following box and attach an additional CO-931 form listing additional beneficiaries.

If applicable, the provisions of a "QDRO", filed and accepted by the Retirement Services Division, will be applied prior to any distribution to the beneficiaries listed below.

NAME OF BENEFICIARY (Last, First, M.I.) (23)

SOCIAL SECURITY NO. (24)

NAME OF BENEFICIARY (Last, First, M.I.) (30)

SOCIAL SECURITY NO. (31)

CONTINGENT

ADDRESS (Street No., Name) (25)

RELATIONSHIP (26)

ADDRESS (Street No., Name) (32)

RELATIONSHIP (33)

(City, State, Zip Code)  (27)

PERCENT (28)

DATE OF BIRTH (29)

(City, State, Zip Code)  (34)

PERCENT (35)

DATE OF BIRTH (36)

NAME OF BENEFICIARY (Last, First ,M.I.) (37)

SOCIAL  SECURITY NO. (38)

NAME OF BENEFICIARY (Last, First, M.I.)  (44)

SOCIAL  SECURITY NO. (45)

CONTINGENT

CONTINGENT

ADDRESS (Street No., Name) (39)

RELATIONSHIP (40)

ADDRESS (Street No., Name) (46)

RELATIONSHIP (47)

(City, State, Zip Code)  (41)

PERCENT (42)

DATE OF BIRTH (43)

(City, State, Zip Code)  (48)

PERCENT (49)

DATE OF BIRTH (50)

Employee's Initials

Agency Staff's Initials

 
     
     
     

DESIGNATION OF RETIREMENT SYSTEM-TIER-PLAN-BENEFICIARY

CO-931 REV. 11/2013

STATE OF CONNECTICUT
OFFICE OF THE STATE COMPTROLLER
RETIREMENT SERVICES DIVISION

Page 3 of 3

V. MEMBER'S STATEMENT

I have read the information provided on this form and understand that I can find a description of my benefits, rights and responsibilities under the SERS and TRS retirement systems in their respective Summary Plan Descriptions and other plan information located on the websites noted in Section III of this form.  I acknowledge that prior to signing this form, I had an opportunity to review these descriptions, ask questions and obtain additional information with regard to the provisions of the retirement system available to me as a State employee prior to making my retirement plan choice, if eligible.  I understand the provisions of the retirement system I have irrevocably elected in Section III and that I will be required to make contributions based upon my retirement plan designation.

I further understand that this is a one-time Election and that my choice of retirement plan is irrevocable; that is I must remain in the retirement plan I have chosen in Section III throughout my entire employment with the State of Connecticut until and unless retirement plan provisions as outlined in Section III require such a change.

I understand that if it is subsequently determined that I was not eligible to participate in the plan I have selected, or was ineligible to make any election at the time my election was made, my election will be considered invalid and will be reversed.

Further, I hereby revoke all previous appointments of beneficiaries made by me, if any, and designate the person(s) named in Section IV of this form as beneficiary(ies) such person(s) to receive upon my death any lump sum benefits 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.

I understand that if applicable, the provisions of a "QDRO", filed and accepted by the Retirement Services Division, will be applied prior to any distribution to my beneficiaries.

EMPLOYEE'S SIGNATURE (51)

DATE (52)

AUTHORIZED AGENCY SIGNATURE (& TITLE) (53)

PHONE (54)

DATE (55)

Forward completed form to: Retirement Services Division, Data Base Unit, 55 Elm Street, Hartford, CT 06106.  Agency should retain one copy and provide one copy to employee.