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HomeMy WebLinkAbout03-112 t OUT-OF-STATE CREDIT AUTHORIZATION M Resolution No. 03-112 R IMRF Form 6.33 (Rev. 3/93) f INSTRUCTIONS AND REQUIREMENTS ON REVERSE SIDE PLEASE PRINT OR TYPE Member's Last Name First Middle Initial Social Security Number F3i~L✓� .lr-tit's fr s —r• Present Position Current Position Su pee,. DF *APeR.lnst Ji C- S 2KS Current Employer Name Employer Number rrY ©P. U t (State SSA Number) 69-033 11 3 LI Certification by Member I certify that I was an employee of TExs• 44.1...‘ Lf4 l tJE1�s�T- Name of Local Government Tt=, •� from Og l)l/8) to t 2'4)1/1 1 Name of State Date Date in the position(s)of (14►JV >C.o.1FE Coi.1ST�'.t�GTi[>r`1 SUPT=E�' x/1 12 such service having been covered under —ray-AS .Efl Ct>rl'Ae-1T S` 'S1 Ed1 COfz.P ,) A+ ,N\ 4-44 J cEe Name of Public Employee Pension System whose address is rvidar UtW►l/,, aerie c t `T"X L 77 1 Street 'City State 1 Zip Code and that I have irrevocably forfeited all service credits in said pension system and am not entitled to benefits of any type therefrom.I understand that no service credit will be established under the Illinois Municipal Retirement Fund until I have made the required payment to IMRF. 5/.2 C>3 _ _ -.._ , 1`.i 84-Z 31—!o l 2-4-• Date Member's Signa •re Member's Daytime Telephone No. Certification by Clerk or Secretary of Governing Body I certify that a regular or special meeting held on ,the Date Name of Governing Body of _authorized the granting of service credits for out-of-state service with Name of Governmental Unit the out-of-state governmental unit named herein from to (not to exceed 120 Date Date months for the above named member). Date Clerk or Secretary Signature Illinois Municipal Retirement Fund Suite 500, 2211 York Road, Oak Brook Illinois 60521-2374 708/368-1010 IMRF Form 6.33 (Rev. 3/93) Service Representatives 800/ASK-IMRF