HomeMy WebLinkAbout04-61 r-.nnk,n i u, cuu4 VOLUME LXIX
M OUT-OF-STATE CREDIT AUTHORIZATION 04- lel
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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 Social Securi Number
Tsh • ROuett
City,State,and ZIP Current Position
E`5inila.. (DO1 a3 ' dtct (Us , Coo rrw a1
Current Employer Name Employer Number
CA o Etnt►—,
Certification by Member y
I certify thatll I was an employee of _ v\ _ _ t=-C�tarn -ZOO
Local
�l l 1 q c�.lrl from) �1UC//1 Name dd}l�a_toe�
`Named state � � /� Da res C ate ��
in the position(s)of _ eV Qni'Y`QnlaD ACCrarrhr0 .? t-a '" _
such service having been covered under fl 2L.\a lrnZ Q�J,t,),p p� p 1LQ rice/ � ,-r
Name d P Ic Em y�l ee Pension System whose address is _ c)
I am azQ ) T 149 009
Street Ctty 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 crecfit will be established under the Illinois Municipal Retirement Fund until I have made the
required payment to IMRF.
______14a411411 L VA.A—./k CO_
r Date Members Signature s Daytime Telephone No.
Certification by Clerk or Secretary of Governing Body
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I certify that a regular or special meeting held on J-/e- ,the t:�.
/frz - '(, L-L _
� � Date Named Governing Body
of /i r (1 —_ ---- authorized the granting of service credits for out-of-state service with
N of tat Unit
the out-of-state governmental unit named herein from _' 13 to '3_ / 9 9 (not to exceed 120
Date Date
months for the above named member. a
til
3-/0:4
Date f 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 (1-804275-4673)
IMRF Form 6.33 (Rev.6/99)
286