New Retirement Form Demographic InformationType of Request?* Initial Request Revised Request Please indicate which specific field has been revised.Legal Name First Middle Last Retirement Date ( must be the 1st of a month)* MM slash DD slash YYYY Employee Date of Birth MM slash DD slash YYYY Employee Date of Marriage (if married) MM slash DD slash YYYY Employee ID Number (must be 6 digits)* UConn Email Address Personal Email Address Telephone Number (work)Telephone Number (home)Telephone Number (cell)Home Address as of Retirement Date (cannot be a P.O. Box) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Retirement PlansCurrent Retirement PlanChoose OneSERS (including Hybrid)Alternate Retirement Plan (ARP)Benefit Payment Option Straight Life Annuity (no benefits are payable after your death, and health insurance terminates for any dependents enrolled in retiree health insurance.) 50% Spouse (50% of your payment and lifetime retiree health insurance continues after your death to a surviving spouse.) 50% Annuitant – non-spouse (50% of your payment continues after your death to a survivor. Only one annuitant may be selected and can never be changed.) 100% Spouse (100% of your payment and lifetime retiree health insurance continues after your death to a surviving spouse) 100% Annuitant – non-spouse (100% of your payment continues after your death to a survivor. Only one annuitant may be selected and can never be changed.) 10 Year Period Certain (If you pass away within first 10 years of retirement, payments continue to annuitant(s) for balance of 10 year period. Multiple annuitants may be selected.) 20 Year Period Certain (if you pass away within the first 20 years of retirement, payments continue to annuitant(s) for balance of 20 year period. Multiple annuitants may be selected.) Hybrid Cash-out option ANNUITANT INFORMATIONPlease provide the following information for your spouse or annuitant(s).Name First Middle Last Date of Birth MM slash DD slash YYYY RelationshipSelect OneSpouseChildDependentOtherADDITIONAL ANNUITANT INFORMATIONPlease provide the following information for your spouse or annuitant(s).Name First Middle Last Date of Birth MM slash DD slash YYYY Relationship MEDICARE INFORMATIONWill you be age 65 or older at retirement and be enrolling in Retiree Medical Benefits? Yes No Are you currently enrolled in Medicare? Yes No Please identify your Medicare ID number and effective date of coverage, as identified on your medicare card.Part A Number and Effective Date Part B Number and Effective Date (if applicable) Will your spouse be age 65 or older at retirement and be enrolled under your retiree health coverage? Yes No Is your spouse currently enrolled in Medicare? Yes No Please identify your spouses Medicare ID number and effective date of coverage, as identified on your medicare card.Part A Number and Effective Date Part B Number and Effective Date (if applicable) Have you been assisted by a Benefits Representative with your Retirement Questions? Yes No Name of Benefits Representative: Special Instructions/Comments: Upon receipt of your request, Human Resources will assign your retirement to a Benefits Specialist who will contact you with next steps.CommentsThis field is for validation purposes and should be left unchanged.