Office of the State Comptroller
Retirement Services Division

INSTRUCTIONS
FOR
COMPLETION
OF
FORM CO-931, "DESIGNATION OF RETIREMENT SYSTEM-TIER-PLAN-BENEFICIARY"
Rev. 10-2008

A. NEW EMPLOYEE

B. RE-EMPLOYED, MULTIPLE EMPLOYMENT

C. AGENCY TRANSFER

D. EMPLOYEE NAME AND/OR ADDRESS CHANGE

E. CHANGE IN BENEFICIARY(IES)

F. CHANGE IN RETIREMENT SYSTEM INFORMATION ONLY


A. NEW EMPLOYEE

This section applies only to those employees with no prior state service. For those employees with prior state service - regardless of when such service occurred - refer to Section B. RE-EMPLOYED, MULTIPLE EMPLOYMENT beginning on page seven of these instructions.

IMPORTANT: A form CO-931 is required for each new employee with the exception of state university part-time lecturers and University of Connecticut special payroll lecturers who waive participation in a retirement plan or individuals employed in the following classifications:

Classification     Compensation Class Code
Patient/Inmate Worker    6149
State University Assistants    8105
University Student Laborer    9098
Graduate Assistant    4185
Student Laborer/Student Worker    8152
Student Worker    0444

Refer to the Retirement Services Division memoranda dated March 5, 2008 and May 12, 2008 for specific procedures applicable to state university part-time lecturers and University of Connecticut (UConn) special payroll lecturers who elect to waive their participation in a retirement plan.

At the top of the CO-931 form, check the box labeled NEW EMPLOYEE.

Section I. EMPLOYEE INFORMATION
 
Blocks (1) through (8) Complete for all employees.
Blocks (9) and (10), Complete only if Block (8) is marked MARRIED, otherwise leave blank.
Blocks (11), (11a) and (12) Complete for all employees.
Blocks (13) and (14) should be NO for all new employees.
Blocks (15), (16) and (17) leave blank.
 
Section II. RETIREMENT INFORMATION

Membership in the State Employees Retirement System (SERS) Tier IIA retirement plan commences upon employment for all state employees hired after July 1, 1997 unless they elect membership in another state retirement system, are employed in a classification excluded from retirement system coverage or waive participation.

Please note: new Tier IIA employees must also submit, along with the CO-931 a completed Form CO-1088, "Retirement Credit Purchase Request For Prior Miscellaneous Service-Tier IIA Members Only".

Teachers or professional staff members described in Connecticut General Statutes, Section 5-160(g), first hired after July 1, 1997 are covered under Tier IIA unless they are eligible for and elect membership the Teachers Retirement System (TRS) or the Alternate Retirement Program (ARP) within six months after commencement of employment. Part-time lecturers and adjunct faculty employed within the State system of higher education have ninety days within which to make an election. (Refer to the Retirement Services Division memoranda dated March 5, 2008 and May 12, 2008 for specific procedures governing these employees' retirement plan enrollment.)

A CO-931 form must be completed for eligible teachers or professional staff members at the time of employment even if they have not yet made a decision which retirement plan to choose. See the instructions on page five of these instructions for completion of Block (18)(h) OTHER by eligible undecided employees. When these employees make a retirement system election, they must complete a second CO-931 form for a CHANGE IN RETIREMENT SYSTEM INFORMATION ONLY. Eligible, undecided employees who fail to make a valid retirement plan election within the required period (90 days for adjuncts and part-time lecturers, six months for all others) will be automatically enrolled in SERS. (In the case of UConn special payroll lecturers, automatic enrollment will be made to ARP.)

IMPORTANT: Once an employee has made a retirement plan election that decision cannot be changed. However, if an employee who initially elected ARP or TRS transfers to a position that is not eligible for ARP or TRS participation, the employee must be enrolled in SERS. For the rules regarding retirement system membership for dual employment please refer to Section B. RE-EMPLOYED, MULTIPLE EMPLOYMENT beginning on page seven of these instructions.

For employees who are ineligible for retirement system membership, please also see the instructions for completion of Block (18)(h) OTHER on page five of these instructions.

Check the appropriate RETIREMENT SYSTEM box in Block (18).
 
The following instructions explain the completion of Blocks (19) through (26c) for each Retirement System selected.
 
(18)(a) STATE EMPLOYEES
(19) Tier IIA for all new hires. Check box if employee has been hired in a designated hazardous duty classification.
(20) Should be blank for new employees.
(21) Enter code RSE2A for non-hazardous duty or code RS2AHZ for hazardous duty.
(22) Enter the 2 digit Core-CT union code.
(23) Enter the 6 digit Core-CT job code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Leave blank.
 
(18)(b) ALTERNATE RETIREMENT PROGRAM
(19), (20) Leave blank.
(21) Enter code RARPSS.
(22) Enter the 2 digit Core-CT union code.
(23) Enter the 6 digit Core-CT job code.
(24), (25) Check appropriate boxes.
(26a) Enter the name of the Insurance Company/Carrier. [ING]
(26b) Check the appropriate box for deduction election.
(26c) Enter start date of payroll period when plan deductions will commence.

(18)(c) JUDGES, FAMILY SUPPORT MAGISTRATES & COMPENSATION COMMISSIONERS
(19), (20) Leave blank.
(21) Enter code RETJUD for Judges or code RCPCMR for Family Support Magistrates and Compensation Commissioners.
(22) Enter the 2 digit Core-CT union code.
(23) Enter the 6 digit Core-CT job code.
(24), (25) Check appropriate boxes.
(26a), (26b), (26c) Leave blank.
 
(18)(d) PROBATE COURT JUDGES & EMPLOYEES
(19), (20) Leave blank.
(21) Enter code 4.
(22) Leave blank.
(23) Enter the 4 digit Probate Court District identification code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Leave blank.
 
(18)(e) PUBLIC DEFENDERS
(19), (20) Leave blank.
(21) Enter code RPUBDF.
(22) Enter the 2 digit Core-CT union code.
(23) Enter the 6 digit Core-CT job code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Leave blank.
 
(18)(f) STATES ATTORNEY
(19), (20) Leave blank.
(21) Enter code RSTATY.
(22) Enter the 2 digit Core-CT union code.
(23) Enter the 6 digit Core-CT job code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Leave blank.
 
(18)(g) TEACHERS RETIREMENT SYSTEM
(19), (20) Leave blank.
(21) Enter code RTRSSS (with FICA) or code RTRNSS (with no FICA)
(22) Enter the 2 digit Core-CT union code.
(23) Enter the 6 digit Core-CT job code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Leave blank.
(18)(h) OTHER

Please specify either "Ineligible" or "Undecided".
(19), (20) Leave blank.
(21) Enter code RNRNSS (with no FICA) or code RNRSS (with FICA) for employees ineligible for retirement system membership.
Enter RETUND for undecided employees who are eligible to choose membership in SERS, TRS or ARP within six months from date of employment (90 days for part-time lecturers and adjunct faculty). When these employees make a retirement system election, they must complete a CO-931 form for a CHANGE IN RETIREMENT SYSTEM INFORMATION ONLY. Please note: employees who chose membership in SERS will be required to make mandatory Tier IIA retirement contributions for the period between the employee's date of employment and the date when retirement deductions commence; ARP membership is not retroactive and begins at the time of the employee's election of ARP membership.
(22) Enter the 2 digit Core-CT union code.
(23) Enter the 6 digit Core-CT job code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Must be blank. For ALTERNATE RETIREMENT PROGRAM use only.
 
Section III. BENEFICIARY INFORMATION
 
Complete Blocks (27) through (33) for each designated beneficiary
If an employee does not designate a beneficiary, any lump sum benefits payable upon death will be paid to his/her estate.
 
If an employee wants to designate a primary and contingent beneficiary, he/she must check the box labeled "contingent" in Block 27 to identify any contingent beneficiary (otherwise all beneficiaries will be treated as primary).

If an employee designates more than one beneficiary but fails to complete Block 32, Percent, each beneficiary will receive an equal share of any amounts due.

An employee who wants to designate more than four beneficiaries, must check the appropriate box on the first line of the Beneficiary section and attach a second CO-931 form listing additional beneficiaries.

Block (33) Provide Date of Birth for each beneficiary. Please note that payment methods for minor payees are governed by statute.
 
Section IV. MEMBER'S STATEMENT
 
Blocks (34) and (35) The employee must sign and date the CO-931 form.
Blocks (36) through (38) An authorized agency staff member must sign and date the
form and enter his/her title and telephone number.

B. RE-EMPLOYED, MULTIPLE EMPLOYMENT

This section applies to those employees who previously terminated State service and are now being re-employed, who retired from State service and are being either permanently or temporarily re-employed, or who are now and will continue to be concurrently employed by two or more State agencies.

If employee is transferring from one agency to another refer to Section C. AGENCY TRANSFER.

At the top of the CO-931 form, check the box labeled RE-EMPLOYED, MULTIPLE EMPLOYMENT.

Section I. EMPLOYEE INFORMATION

Blocks (1) through (8) Complete for all employees.
Note: Block (3) Do not assign a new employee number. Contact the Retirement Services Division, Data Base Unit, to obtain the employee number originally assigned to the employee.
Blocks (9) and (10) Complete only if Block (8) is marked MARRIED, otherwise leave blank.
Blocks (11), (11a) and (12) Complete for all employees.
Block (13) Complete for employees currently working at another State agency.
Block (14) Should be marked YES for all re-employed employees.
Blocks (15), (16) and (17) Complete for all employees.

Section II. RETIREMENT INFORMATION

Employees with prior SERS membership who are rehired after a permanent break in service are treated as new employees for retirement plan membership purposes and should be provided with the retirement plan election options appropriate to the position for which he/she is hired.

Employees who are rejoining SERS should be placed in the appropriate tier and plan according to current SERS plan provisions.

Teachers or professional staff members as described in Connecticut General Statutes, Section 5-160(g), with prior State service must rejoin the retirement plan (SERS, TRS or ARP) to which they were previously assigned. Note: Those State university part-time lecturers and UConn special payroll lecturers who were eligible to and waived retirement plan participation during prior employment are ineligible for retirement plan membership during subsequent part-time employment within the State system of higher education. If such employee is subsequently rehired to a full-time position, he of she must be offered the retirement plan election options appropriate to that position. Retirement plan participation cannot be waived by an employee in a full-time position.

Temporarily re-employed SERS and ARP retirees can work a maximum of 120 days or 45.97% of a full-time teaching schedule in a calendar year without engaging the pension suspension provisions of Connecticut General Statutes, Section 5-164a (c). For such employees a form CO-1208, "Temporary Post Retirement Reemployment" must be completed.  Please see Retirement Services Memorandum 2010-02 dated February 18, 2010 for complete instructions.

SERS Tier I retirees who are re-employed on a permanent basis may elect to resume their SERS Tier I membership and make any required contributions to the retirement fund upon their completion of not less than six months of continuous service. SERS Tier II and Tier IIA retirees who are re-employed on a permanent basis must immediately resume their SERS membership at the time of their reemployment.

Retired members of TRS who accept State employment in teaching positions are not eligible to accrue additional benefits under TRS and cannot join either ARP or SERS. The exception to this rule is for retired TRS members who have only non-state, public school service. These employees only will be permitted to join SERS or, if eligible, ARP as a new State employee. All retired members of TRS are subject to restrictions on post-retirement teaching imposed by CGS 10-183v.

Individuals who are currently employed at another State agency must remain in the retirement plan (SERS, TRS or ARP) in which they are enrolled. Those state university part-time lecturers and UConn special payroll lecturers who were eligible to and elected to waive participation in a retirement plan are not eligible to elect retirement plan membership during any part-time employment with a Connecticut Community College. Individuals who accept secondary employment as a State university part-time lecturer or a UConn special payroll lecturer must remain in the retirement plan in which they are enrolled in their primary employment during any supplemental State university or UConn service.

Check the appropriate RETIREMENT SYSTEM box in Block (18).

The following instructions explain the completion of Blocks (19) through (26c) for each RETIREMENT SYSTEM.

(18)(a) STATE EMPLOYEES
(19) Check Tier I, Tier II or Tier IIA depending upon the employee's prior retirement system membership, the length of prior service credit and the length of any break in service. Also indicate whether employee has been hired in a designated hazardous duty classification. Dually employed SERS members must retain the same tier and plan membership designated for their primary employment. If you have any questions regarding the appropriate Tier placement for a re-employed employee contact the Retirement Services Division, Data Base Unit.
(20) Complete only if Tier I is checked in Block (19).
(21) Enter the retirement deduction code applicable to the employee's Tier placement and hazardous duty status. Contact the Retirement Services Division, Data Base Unit, for help with the appropriate retirement deduction code.
(22) Enter the 2 digit Core-CT union code.
(23) Enter the 6 digit Core-CT job code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Leave blank.


(18)(b) ALTERNATE RETIREMENT PROGRAM
(19), (20) Leave blank.
(21) Enter code RARPSS for all new ARP members. Code RARNSS may be appropriate for certain members based upon their prior ARP service. Contact the Retirement Services, Data Base Unit for assistance with the appropriate retirement deduction code.
(22) Enter the 2 digit Core-CT union code.
(23) Enter the 6 digit Core-CT job code.
(24), (25) Check the appropriate boxes.
(26a) Enter the name of the Insurance Company/Carrier. [ING]
(26b) Check the appropriate box for deduction election.
(26c) Enter start date of payroll period when deductions will commence.

(18)(c) JUDGES, FAMILY SUPPORT MAGISTRATES & COMPENSATION COMMISSIONERS
(19), (20) Leave blank.
(21) Enter code RETJUD for Judges or code RCPCMR for Family Support Magistrates and Compensation Commissioners.
(22) Enter the 2 digit Core-CT union code.
(23) Enter the 6 digit Core-CT job code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Leave blank.

(18)(d) PROBATE COURT JUDGES & EMPLOYEES
(19), (20) Leave blank.
(21) Enter code 4.
(22) Leave blank.
(23) Enter the 4 digit Probate Court District identification code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Leave blank.

(18)(e) PUBLIC DEFENDERS
(19),(20) Leave blank.
(21) Enter code RPUBDF.
(22) Enter the 2 digit Core-CT union code.
(23) Enter the 6 digit Core-CT job code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Leave blank.

(18)(f) STATES ATTORNEY
(19), (20) Leave blank.
(21) Enter code RSTATY.
(22) Enter the 2 digit Core-CT union code.
(23) Enter the 6 digit Core-CT job code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Leave blank.

(18)(g) TEACHERS RETIREMENT SYSTEM
(19), (20) Leave blank.
(21) Enter either RTRSSS (with FICA) or code RTRNSS (with no FICA).
(22) Enter the 2 digit Core-CT union code.
(23) Enter the 6 digit Core-CT job code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Must be blank.

(18)(h) OTHER
Please specify "Ineligible", "Undecided", "Temporarily Re-employed TRS Retiree" or "Permanently Re-employed Retiree - 1st Six Months".
(19), (20) Leave blank.
(21) Enter either code RNRNSS (with no FICA) or code RNRSS (with FICA) for employees ineligible for retirement system membership.
Enter code RETUND for undecided employees eligible to choose membership in SERS, TRS or ARP within six months of their date of employment (90 days for part-time lecturers and adjunct faculty). When these employees make a retirement system election, they must complete a CO-931 form for a CHANGE IN RETIREMENT SYSTEM INFORMATION ONLY. Please note: employees who chose membership in SERS and whose appropriate Tier placement is either Tier I or Tier IIA will be required to make mandatory retirement contributions for the period between the employee's date of employment and the date when retirement deductions commence; ARP membership is not retroactive and begins at the time of the employee's election of ARP membership.

Enter code RNRSS for a retired SERS Tier I member reemployed on a permanent basis until they have completed six months of continuous employment. At the end of that period the employee must complete a second CO-931 form for a CHANGE IN RETIREMENT SYSTEM INFORMATION ONLY reflecting the resumption of retirement plan membership.
Enter either RNRNSS (with no FICA) or code RNRSS (with FICA) for reemployed TRS retirees ineligible for retirement system membership.
(22) Enter the 2 digit Core-CT union code.
(23) Enter the 6 digit Core-CT job code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Leave blank.

Section III. BENEFICIARY INFORMATION

Blocks (27) through (33). Complete for each designated beneficiary

With the exception of temporarily reemployed retires, all employees rehired in State service must make a new beneficiary designation on reemployment; previous
beneficiary(ies) designation(s) will not be retained. If an employee does not choose to designate a beneficiary, any lump sum benefit payable upon the employee's death will be refunded to his/her estate.

If an employee wants to designate a primary and contingent beneficiary, he/she must check the box labeled "contingent" in Block 27 to identify any contingent beneficiary (otherwise all beneficiaries will be treated as primary).

If an employee designates more than one beneficiary but fails to complete Block 32, Percent, each beneficiary will receive an equal share of any amounts due.

An employee who wants to designate more than four beneficiaries, must check the appropriate box on the first line of the Beneficiary section and attach a second CO-931 form listing additional beneficiaries.

Block (33) Provide Date of Birth for each beneficiary. Please note that payment methods for minor payees are governed by statute.

Section IV. MEMBER'S STATEMENT

Blocks (34) and (35) Employee must sign and date the CO-931 form.

Blocks (36) through (38) An authorized agency staff member must sign and date the form and enter his/her title and telephone number.

C. AGENCY TRANSFER

This section applies only to those employees who are making an immediate transfer to another agency without any break in service.

At the top of the CO-931 form, check the box labeled AGENCY TRANSFER.

Section I. EMPLOYEE INFORMATION
 
Blocks (1) through (8), complete for all employees. Block (4) should be the date on which the employee begins service with the new agency.
Blocks (9) and (10), complete only if Block (8) has been checked MARRIED, otherwise skip.
Blocks (11), (11a), and (12), complete for all employees.
Block 13 should be NO for agency transfers. For an individual who is dually employed refer to B. RE-EMPLOYED, MULTIPLE EMPLOYMENT on page seven of these instructions.
Blocks (14) through (15) complete with information from the former agency.
Block (16) Should be one day before the Date of Employment in Block (4).
 
Section II. RETIREMENT INFORMATION

A SERS member who is making a direct transfer from one State agency to another must retain the same SERS Tier and plan membership unless their employment change provides them for the first time with an opportunity to elect membership in another State retirement system, such as ARP or TRS.

A SERS member who is experiencing a change in job classification either from a hazardous duty classification to a non-hazardous duty classification or vice versa must be enrolled in the appropriate non-hazardous duty or hazardous duty plan within his or her Tier membership.

An ARP member who is making a direct transfer from one State agency to another must retain ARP membership unless the transfer is to an agency where ARP participation is not allowed; under such circumstance the employee must enroll in SERS.

If you have any questions regarding the appropriate retirement plan membership for an employee transferring from another state agency, contact the Retirement Services Division, Data Base Unit.

Check the appropriate RETIREMENT SYSTEM box in Block (18).
 
The following instructions explain the completion of Blocks (19) through (26c) for each RETIREMENT SYSTEM.
 
(18)(a) STATE EMPLOYEES
(19) Check Tier I, Tier II or Tier IIA based on employee's previous membership. Also check box if employee has been hired into a designated hazardous duty classification.
(20) Complete only if Tier I is checked in Block (19).
(21) Enter the appropriate retirement deduction code based upon the employee's Tier placement and hazardous duty status. Contact the Retirement Services Division, Data Base Unit, if you have any questions regarding the appropriate retirement deduction code.
(22) Enter the 2 digit Core-CT union code.
(23) Enter the 6 digit Core-CT job code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Leave blank.

(18)(b) ALTERNATE RETIREMENT PROGRAM
(19), (20) Leave blank.
(21) Enter code RARPSS for all new ARP members. Code RARNSS may be appropriate for certain members based upon their prior ARP service. Contact the Retirement Services, Data Base Unit for assistance with the appropriate retirement deduction code.
(22) Enter the 2 digit Core-CT union code.
(23) Enter the 6 digit Core-CT job code.
(24), (25) Check the appropriate boxes.
(26a) Enter the name of the Insurance Company/Carrier [ING].
(26b) Check the appropriate box for deduction election.
(26c) Enter the start date of the payroll period when deductions will commence.
 
(18)(c) JUDGES, FAMILY SUPPORT MAGISTRATES & COMPENSATION COMMISSIONERS
(19), (20) Leave blank.
(21) Enter code RETJUD for Judges or code RCPCMR for Family Support Magistrates and Compensation Commissioners.
(22) Enter the 2 digit Core-CT union code.
(23) Enter the 6 digit Core-CT job code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Leave blank.
 
(18)(d) PROBATE COURT JUDGES & EMPLOYEES
(19), (20) Leave blank.
(21) Enter code 4.
(22) Leave blank.
(23) Enter the 4 digit Probate Court District identification code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Leave blank.
 
(18)(e) PUBLIC DEFENDERS
(19),(20) Leave blank.
(21) Enter code RPUBDF.
(22) Enter the 2 digit Core-CT union code.
(23) Enter the 6 digit Core-CT job code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Leave blank.

(18)(f) STATES ATTORNEY
(19), (20) Leave blank.
(21) Enter code RSTATY.
(22) Enter the 2 digit Core-CT union code.
(23) Enter the 6 digit Core-CT job code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Leave blank.
 
(18)(g) TEACHERS RETIREMENT SYSTEM
(19), (20) Leave blank.
(21) Enter either RTRSSS (with FICA) or code RTRNSS (with no FICA).
(22) Enter the 2 digit Core-CT union code.
(23) Enter the 6 digit Core-CT job code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Must be blank.
 
(18)(h) OTHER
Only applicable if employee is transferring to a position not eligible for retirement membership.
(19), (20) Must be blank. For STATE EMPLOYEES use only.
(21) Enter either code RNRNSS (with no FICA) or code RNRSS (with FICA) for employees ineligible for retirement system membership. Contact the Retirement Services Division, Data Base Unit, if you have any questions regarding the appropriate retirement deduction code.
(22) Enter the 2 digit Core-CT union code.
(23) Enter the 6 digit Core-CT job code.
(24), (25) Check the appropriate boxes.
(26a), (26b), (26c) Leave blank. For ALTERNATE RETIREMENT PROGRAM use only.
 
Section III. BENEFICIARY INFORMATION
 
Complete Blocks (27) through (33) for each designated beneficiary.

If an employee does not choose to designate a beneficiary, his or her former designation(s) will remain in effect.

Block (33) Provide Date of Birth for each beneficiary. Please note that payment methods for minor payees are governed by statute.

Section IV. MEMBER'S STATEMENT

Blocks (34) and (35) Employee must sign and date the CO-931 form.
Blocks (36) through (38) An authorized agency staff member must sign and date the form and enter his/her title and telephone number.

D. EMPLOYEE NAME AND/OR ADDRESS CHANGE

At the top of the CO-931 form, check the box labeled EMPLOYEE NAME AND/OR ADDRESS CHANGE.

Underline or circle the action(s) which applies to the type of change(s) being made.

It is anticipated that employee name and address changes that have been processed through Core-CT will be automatically updated in the State Employees Data Base in the future. Consequently, completion of a CO-931 form will not be necessary for individuals employed at agencies using Core-CT HRMS.

Important Note: In the case of a name and address change resulting from a change in an employee's marital status, the employee should be advised that a CO-931 form must be completed if they wish to change their designated retirement beneficiary(ies).

Section I. EMPLOYEE INFORMATION
 
Blocks (1), (2), and (3) Complete for all employees.
Block (7) Complete for a change of address.
Blocks (8), (9) and (10) Complete for a name and marital status change.
Blocks (11), (11a) and (12) Complete for all employees.
Block (17) Complete for a name change.
 
Section IV. MEMBER'S STATEMENT
 
Blocks (34) and (35) Employee must sign and date the form.
Blocks (36) through (38) An authorized agency staff member must sign and date the form and enter his/her title and telephone number.

E. CHANGE IN BENEFICIARY(IES)

Any CO-931 form received for a change in beneficiary(ies) represents a permanent change in the member's beneficiary designation. Any and all former designations are revoked and the new designation will remain in effect unless the member subsequently completes a new CO-931 form changing his or her beneficiary designation.

Complete Blocks (27) through (33) for each designated beneficiary.
 
If an employee wants to designate a primary and contingent beneficiary, he/she must check the box labeled "contingent" in Block 27 to identify any contingent beneficiary (otherwise all beneficiaries will be treated as primary).

If an employee designates more than one beneficiary but fails to complete Block 32, Percent, each beneficiary will receive an equal share of any amounts due.

An employee who wants to designate more than four beneficiaries, must check the appropriate box on the first line of the Beneficiary section and attach a second CO-931 form listing additional beneficiaries.

Block (33) Provide Date of Birth for each beneficiary. Please note that payment methods for minor payees are governed by statute.
 
Section IV. MEMBER'S STATEMENT
 
Blocks (34) and (35) Employee must sign and date the form.

Blocks (36) through (38) An authorized agency staff member must sign and date the form and enter his/her title and telephone number.

F. CHANGE IN RETIREMENT SYSTEM INFORMATION ONLY

This section applies only to those employees who are changing retirement system, tier, and/or plan membership as a result of a change in employment status, which either necessitates such change or provides the employee with an option not previously available. To accomplish this change a CO-931 form must be completed for:

At the top of the CO-931 form, check the box labeled CHANGE IN RETIREMENT INFORMATION ONLY.

Section I. EMPLOYEE INFORMATION
 
Blocks (1), (2) and (3) Complete for all employees.
Block (4) Enter the effective date of the retirement system change.
Blocks (11), (11a), (12) and (13) Complete for all employees.
 
Section II. RETIREMENT INFORMATION
 
Complete Blocks (18) through (26c) as applicable.
Please contact the Retirement Services Division, Data Base Unit, if you have any questions regarding the appropriate retirement information.
 
Section IV. MEMBER'S STATEMENT
 
Blocks (34) and (35) Employee must sign and date the form.

Blocks (36) through (38) An authorized agency staff member must sign and date the form and enter his/her title and telephone number.

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