CT_DIS_RET_SURVEY

Under the State Employees Retirement Act, the disability retirement benefit you receive from the State Employees Retirement System ("SERS") may be adjusted or suspended under a variety of circumstances. These circumstances include both (i) your receipt of income in the form of workers' compensation benefits, Social Security benefits for you or members of your family, benefits paid under Section 5-142 of the Connecticut General Statutes, and/or earnings from employment or self-employment; and (ii) any change to the amount of such income you receive. An adjustment or suspension may also be based on a change in your health that affects your ability to work.

To help us determine whether an adjustment is necessary, every disability retiree must complete an annual disability retirement survey ("Survey"). You must complete the Survey, and you may do so in either of two ways: (i) by completing the online version below or (ii) by mailing a signed, paper copy, along with any related documents, to:

Retirement Services Division, Attn: Disability Unit, 165 Capitol Avenue, Hartford, CT 06106.

If you fail to complete the Survey by August 16, 2024, your disability retirement benefit could be suspended.

The following Survey requests information about events that occurred between January 1 and December 31, 2023. Please note, however, that you are also required immediately to notify the Division if there is or has been any change, either to your outside income or your ability to work, that is not covered by your response. If you fail to report, or if you delay in reporting, such a change, you risk receiving an overpayment from SERS which you will be responsible for refunding.

Thank you for your cooperation. If you have any questions, please contact the Customer Service Center of the Retirement Services Division, at Osc.Rsd@ct.gov, or at (860) 702-3480.

Please Note Failure to submit the completed survey by August 16, 2024, could result in the suspension of your benefits.

Instructions:This survey calls for information about income you received during the most recent calendar year. You must answer all questions completely. If necessary, mail in additional pages to complete your answers. Please mail all documents to:
Retirement Services Division, Attn: Disability Unit, 165 Capitol Avenue, Hartford, CT 06106.

Did you receive any income other than your Connecticut SERS benefits during the past year?

(If "Yes", complete applicable fields Sections 1.A and/or 1.B below.)

Yes

Section 1A

Source of Income

Start Date

End Date

Monthly Benefit

Lump Sum Payment

Social Security Disability

Social Security Old Age Benefit

Social Security Family Benefit

Workers' Compensation

Section 5-142*

* Section 5-142 benefits are compensation for certain state employees who became temporarily or permanently disabled as a result of conditions or events reflecting the special hazards inherent in their positions, as set forth in Connecticut General Statute § 5-142.

Section 1B

Source of Income (Cont'd)

Amount Recieved in 2023

Employer Name & Address

Self-Employment or a Business You

Own or Operate

Nature of Work Performed

Wages from an Employer other than

the State of Connecticut

Nature of Work Performed

2. The following documents should be mailed to the address above if applicable:

If Social Security began during 2023, send a copy of your Notice of Award.

Copy of W-2 or 1099 forms or Schedule C reflecting money you earned by working in 2023.

3. Emergency Contact: You must identify someone we can contact if we are unable to reach you:

Name:

Telephone No.:

Address:

Email Address:

IMPORTANT - I declare under penalty of perjury that the statements and representations I have provided in this survey, and in any accompanying statements or forms, are true to the best of my knowledge and belief. I understand that any false or misleading statement or omission could affect my right to continue receiving a disability retirement pension.

I further understand that I must promptly notify the Retirement Services Division if:(i) I become employed or self-employed;(ii) I begin to receive workers' compensation, Social Security, or § 5-142 benefits; (iii) a member of my family begins to receive Social Security Disability benefits; (iv) there is a change to the amount of any such benefits paid to me or a member of my family; (v) I engage in any activity that demonstrates an improvement in my medical or psychological condition.

*First Name:

*Last Name:

*Employee ID:

*Signature:

*Date:

*Daytime Phone No:

*Email Address: