HomeMy WebLinkAbout02-216 JUNE 12 , 2002 VOLUME LXVII
1I IMRF BENEFIT PROTECTION LEAVE Resolution No. 02-216
R IMRF Form 6.32 (6/99)
INSTRUCTIONS ON REVERSE
PLEASE PRINT OR TYPE
MEMBER'S LAST NAME FIRST MIDDLE INITIAL SOCIAL SECURITY NUMBER
POTTS, JR., WILLIAM H __ .
STREET(MAILING)ADDRESS CITY,STATE AND ZIP
ELGIN IL 60123
CURRENT POSITION MEMBER'S TELEPHONE NUMBER
UTILITY WORKER-' SEWERS
EMPLOYER NAME EMPLOYER IMRF I .NUMBER
CITY OF ELGIN;
CERTIFICATION BY MEMBER
I certify that I will be(or have been)on leave of absence beginning 9/10/00 and ending 11/13/00
DATE DATE
for a total of 2 months.(Indicate on Line 2 below)
I understand that service credits(not more than 12 months)for this leave cannot be established until I have paid to IMRF member contribu-
tions in an amount equal to the approximate contributions I would have made if actively employed during the leave of absence,plus interest.
MEMBER SIGN TURF DATE
CERTIFICATION BY AUTHORIZED AGENT
I certify that(1)I have calculated the estimated employer cost of the above member's leave,(2)I have advised the governing body of the
amount of such cost and(3)that it will be paid through future monthly contributions.
1. AVERAGE MONTHLY EARNINGS ��"
•
(Determine the monthly average by dividing by 12 the IMRF reported earnings
360587
for the 12 months prior to the leave) $ . y ; •:•
2. NUMBER OF MONTHS LEAVE(LIMITED TO 12 MONTHS) #
2
3. TOTAL ESTIMATED EARNINGS THAT WOULD HAVE BEEN PAID $ H v
DURING THE LEAVE OF ABSENCE(LINE 1 TIMES LINE 2) 7211.74
4. AVERAGE EMPLOYER COST RATE (LINE 3 TIMES 11%) S i r
X11.00%
5. ESTIMATED COST OF THIS LEAVE TO EMPLOYER S £Jx j `3y
�
/ `aC i t�� —may, 793.29 �/ hw ry': .:< :
AUTHORIZED AGENT SIGNATURE / , A• - DATE
N CO��
CERTIFICATION BY CLERK OR SECRETARY OF GOVERNING BODY
I certify that at a regular or special meeting held on June 12,
2002 0 0 2 the City Council
DATE NAME OF GOVERNING BODY
of the City of Elgin approved the leave of absence stated herein and the estimated employer cost as
NAME OF EMPLOYER
herein determined.
SIGNA RE CLERK OR SECRETARY DATE
Dolonna Mecum June 13, 2002
Illinois Municipal Retirement Fund
Suite 500,2211 York Road,Oak Brook Illinois 60523-2374 630/368-1010
IMRF Form 6.32 (Rev.6/99) Service Representative 6O/ASK-IMRF