Form Co 1200 – Fill Out and Use This PDF

APPLICATION FOR MERS RETIREMENT BENEFITS

PART B - Social Security Coverage

PART I - GENERAL EMPLOYER INFORMATION AND INSTRUCTIONS - PLEASE READ CAREFULLY

If you have any questions prior to helping your employee fill out this form, please call the MERS Unit at (860) 702-3500 or visit our website at http://www.osc.ct.gov/rbsd/cmers/index.html for additional information. You must attach the following documents to this application.

(a)The original "Income payment election" (Option A, B, C, or D based upon member's choice).

(b)Copy of member's birth certificate and if applicable, a copy of spouse's or contingent annuitant's birth certificate.

(c)As applicable, a Certification of Marital Status or a Spouse Waiver of Survivor Benefit and/or a Marriage Certificate.

Please mail the original of this application with all of the above attachments to: The MERS Unit, Retirement Services Division, 55 Elm Street, Hartford, CT 06016 at least thirty (30) calendar days prior to the effective date of retirement.

PART II - APPLICANT INFORMATION AND IDENTIFICATION

TYPE OF OPTION ELECTION

PART III - EARNINGS DUE TO RETROACTIVE PAYMENTS (THREE HIGHEST YEARS)

Retroactive payments are retroactive salary increases or retroactive annual increments pursuant to a collective bargaining agreement as the result of an arbitration award. Please list any such payments made during any one of the member's "high three" years. IMPORTANT NOTE: Do not include ANY lump sum reimbursements for accrued sick or vacation time, settlement awards, severance pay or monies contributed to an employee's defined contribution or deferred compensation plan in your calculation of "earnings" under this category. These sums are not to be included in the computation of a member's retirement benefit and contributions should not be made on these monies.

PART IV - LEAVES OF ABSENCE (UNPAID)

PART V - DISABILITY RETIREMENT APPLICATIONS ONLY

If you are applying for a disability retirement benefit, please read this section very carefully. The determination of eligibility for disability retirement benefits is made by the Medical Examining Board (MEB) not MERS. The MEB will base its decision on the pertinent medical evidence you provide which includes information given to it by you, your employer and your medical providers. In addition to this Retirement Application, all applications for disability retirement must include the following three Statements (forms) and requested documentation:

1.CO-1213 Member's Statement - Application for Disability Retirement

2.CO-1214 Physician's Statement - Application for Disability Retirement

3.CO-1215 Employer's Statement - Application for Disability Retirement

It is your responsibility to obtain and send MERS this information. You must apply and submit the required documentation for the disability retirement benefit within one year of your last day of active service with your employer otherwise your Application for Disability retirement will be rejected as untimely.

If the application is for a service connected disability, the application must also include an executed CO-1209, a copy of the "First Report of Injury" and all applicable accident and workers compensation documents and information. Workers compensation payments are an offset to a MERS service connected disability retirement benefit.

Members are required to notify MERS if they currently receive any workers' compensation payments or receive workers compensation payments at any time while collecting a service connected disability benefit.

2. If you are eligible, do you wish to receive a retirement benefit pending the outcome of your disability retirement application?

3. Have you applied for or currently receive social security disability benefits? If yes, attach a copy of your application or social security award letter.

PART VI - SIGNATURES

I acknowledge that prior to signing my application for retirement benefits I had the opportunity to ask questions and obtain additional information from MERS staff with regard to my retirement. I understand that my MERS retirement benefit is reduced when I am eligible for social security (age 62) or earlier if I receive a Social Security disability benefit and that I must inform MERS if I receive a social security disability award prior to the age of 62. I understand that failure to notify MERS of such an award will result in an overpayment being made to me and MERS will recover this overpayment from me and/or my contingent annuitant through the monthly pension payment.

On behalf of the employer, I hereby certify that all the information on the application is correct.