HomeMy WebLinkAbout04-317 •
Resolution No. 04-317
OUT-OF-STATE CREDIT AUTHORIZATION
IMRF Form 6.33 (Rev. 6/99)
INSTRUCTIONS AND REQUIREMENTS ON REVERSE SIDE
PLEASE PRINT OR TYPE
Member's First Name Middle Intial Last Name .
_ fErL.L. _
T Member Mailing Address City,State,and ZIP Current Position
2-S)S Cou.iilli,,,ta_Clp��D 1 I _ ��n� 3 ' tF T: oc pAg -5
Current Employer Name Employer Number
693 34 -7
Certification by Member
I certify that I was an employee of _ CA Ty OF S t X, G t —,
Name of Loail Government
t D 1r jAa
----- from _____ _ Citg---- to ----1��1112-----------
Name of State Date ` Date
In the position(s)of —__--_4t 4 DP 0423,...-4
such service having been covered under _—_ I e' a'''-?
Name of Public Employee Pension System
whose address is JP -D £`c,,,gwf f ?L 1III, DES IYIUI�C— 'r 1__ aD5.._a
Street City State 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.
a/J.5/0-4- .
(gdj
Date Member's Signa 9' re Mem er's Daytime Telephone No.
-- --- -------------- - ---
Certification by Clerk or Secretary of Governing Body
certify thataregul&or special meeting held on 12/1/04 ,the City Council
Date Name of Governing Body
of Ci y of Elgin 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 3/3 0/9 8 to 2/2 8/0 0 --- (not to exceed 120
Date Date
months for the above named member).
l2/1/04 Elgin City Clerk s/ Dolonna Mecum _
Date Clerk or Secretary Signature
Illinois Municipal Retirement Fund
2211 York Road, Suite 500,Oak Brook Illinois 60523-2374, 630/368-1010
Service Representatives 800/ASK-IMRF (1-800-275-4673)
MRF Form 6.33 (Rev.6/99)