OmniForm Form - Western Connecticut State University

DESIGNATION OF RETIREMENT SYSTEM-TIER-PLAN-BENEFICIARY
For Higher Education Employment Only
STATE OF CONNECTICUT
OFFICE OF THE STATE COMPTROLLER
RETIREMENT SERVICES DIVISION
CO-931h Rev. 9/2015
Page 1 of 4
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.
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 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
MULTIPLE
AGENCY
EMPLOYEE NAME AND/
CHANGE IN BENEFICIARY(IES)
RE-EMPLOYED
EMPLOYMENT
EMPLOYEE
TRANSFER
OR ADDRESS CHANGE
NAME AND/OR ADDRESS
CHANGE IN
RETIREMENT SYSTEM
INFORMATION ONLY
I. EMPLOYEE PERSONAL INFORMATION
EMPLOYEE NAME (1) (Last)
M.I.
EMPLOYEE NAME (First)
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
(10)
YES
NO
IF YES, HAS THE ORDER BEEN SUBMITTED TO AND ACCEPTED BY THE RETIREMENT SERVICES DIVISION? (11)
YES
NO
DO YOU HAVE A PENSION DIVISION ORDER ("QDRO") AS A RESULT OF DIVORCE/LEGAL SEPARATION?
II. EMPLOYMENT INFORMATION
EMPLOYING AGENCY (12)
EMPLOYMENT DATE/EFFECTIVE DATE(15)
CORE-CT DEPT ID (13)
BARG UNIT(16)
CORE-CT JOB CODE(17)
AGENCY ADDRESS (14)
EMPLOYMENT STATUS (18)
Full-time
IS EMPLOYEE CURRENTLY EMPLOYED WITH ANOTHER STATE AGENCY? (20) YES
Part-time
TYPE STATUS (19)
Permanent
Temporary
Durational
Intermittent
If YES, provide Agency Name
NO
HAS EMPLOYEE WORKED FOR THE STATE BEFORE? (21)
YES
If YES, provide Agency Name and termination date
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 except as otherwise provided below; this is a
mandatory requirement.
Classified employees - Classified employees in higher education automatically become members of SERS.
Full-Time State Teacher/Full-time or Part-time Professional Staff Member (unclassified) - If you are a full-time employee in a position statutorily
defined as a state teacher or a full-time or part-time professional staff member (unclassified) in higher education you must make an irrevocable
election of membership in State Employees Retirement System (SERS) Tier III, the Alternate Retirement Program (ARP), the SERS Hybrid Plan
or, if eligible, the Teachers Retirement System (TRS) within 60 days of your employment. If you do not make an election within this 60 day
period you will automatically become a member of SERS Tier III.
Adjunct Faculty Members - If you are a part-time, adjunct faculty member in higher education, you must make a one-time irrevocable election of
membership. Your options and plan default are determined based on your place of employment. All elections must be made within 60 days of
your employment or you will automatically default into participation in the retirement plan specified below.
University of Connecticut - You may elect membership in SERS Tier III, ARP, the SERS Hybrid Plan or if eligible, TRS. You may also elect
not to participate in a retirement plan. If you do not make an election, you will automatically become a member of ARP.
Connecticut State Universities, Connecticut Community Colleges and Charter Oak College - You may elect membership in SERS Tier III,
ARP, the SERS Hybrid Plan or if eligible, TRS. You may also elect not to participate in a retirement plan. If you do not make an election,
you will automatically become a member of SERS Tier III.
Your election is irrevocable; no change to an employee's retirement plan membership is permitted after initial election or following 60 day
default. However, if you elect ARP, the SERS Hybrid Plan or TRS membership and are subsequently employed in a position not eligible for
ARP, the SERS Hybrid Plan or TRS participation, you must be enrolled in SERS Tier III. If you previously waived membership in any
retirement plan as a part-time, adjunct faculty member at UCONN or CSU and later become employed in a full-time position you must make an
irrevocable election to join SERS Tier III or, if eligible, ARP, the SERS Hybrid Plan or TRS.
Employee's Initials
Agency Staff's Initials
DESIGNATION OF RETIREMENT SYSTEM-TIER-PLAN-BENEFICIARY
For Higher Education Employment Only
STATE OF CONNECTICUT
OFFICE OF THE STATE COMPTROLLER
RETIREMENT SERVICES DIVISION
CO-931h Rev. 9/2015
Page 4 of 4
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, ARP 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 opportunity to review these descriptions, ask questions and
obtain additional information with regard to the provisions of the retirement systems available to me as a State employee in higher education
prior to making my retirement plan choice. I understand the provisions of the retirement system I have irrevocably elected above 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 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.
If I am eligible to and have elected to waive membership in a retirement plan, I understand that this constitutes an irrevocable waiver of my
rights to participate in any retirement system for any and all of my service as a part-time, adjunct faculty member. I understand that this
means I will not have any right to retirement benefits from the State for any and all employment with the State as a part-time, adjunct faculty
member.
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.
Western Connecticut State University
Change of Employee Address/Name/Emergency Contact
EMPLOYEE NAME: __________________________________________________________________________
Are you a State of Connecticut retiree? Yes
No
NOTE: IF YOU ANSWERED YES TO THE ABOVE QUESTION, YOU MUST CONTACT THE
RETIREMENT DIVISION DIRECTLY AT (860) 702-3517 TO CHANGE YOUR ADDRESS.
ADDRESS CHANGE: (see below Note)
New Address: _________________________________________________________________________
_________________________________________________________________________
New Telephone #: ________________________________________________
NOTE: IF YOU ARE ENROLLED IN ANY OF THE FOLLOWING PROGRAMS: METLIFE, LIBERTY MUTUAL INSURANCE CO.
OR A CREDIT UNION, YOU MUST NOTIFY THEM DIRECTLY TO CHANGE YOUR ADDRESS.
UPDATE EMERGENCY CONTACT INFORMATION:
Name: ________________________________________________________________________________
Address: ______________________________________________________________________________
Telephone #: __________________________________________________________________________
Relationship: __________________________________________________________________________
NAME CHANGE: A COPY OF THE EMPLOYEE’S NEW SOCIAL SECURITY CARD IS REQUIRED FOR A NAME CHANGE.
New Name: __________________________________________________________________________
For HR Office Use Only – Address Change
 Core-CT
 Email Core Security for Name Changes
 Banner - PPAIDEN
 CO-931 form (FT Faculty, Staff & PT Lecturers/Adjuncts Only - Does Not Apply to UA’s, GA’s or Student Workers)
 TIAA-CREF Retirement (if applicable) Employee must call TIAA-CREF 1-800-842-2776 (former accounts only)
 Send e-mail to Purchasing (Karen Muffatti)
 Lecturers, Part-time Coaches and Counselors Only – Copy of Change form to Sarah
Revised 3/2015