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BENEFIT PROTECTION LEAVE 0 " 6�
. IMRF Form 6.32 (Rev. 6/2003)
Avoid delays—read the instructions before completing this form
MBER'S FIRST NAME I MIDDLE INITIAL LAST (JR.SR.II,ETC) SOCIAL SECURITY NUMBER
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STREET(MAILING)ADDRESS CITY,STATE AND ZIP
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bURRENT POSITION MEMBER'S TELEPHONE NUMBER
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EMPLOY R NAME EMPLOYER IMRF I.D.NUMBER
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CERTIFICATION BY MEMBER (If the end date is unknown or in the future)ur
I certify that I will be(or have been)on leave of absence beginning % " 0 3 and ending 11�2-4-03_,
�7 DATE DATE
for a total of ` months. (Indicate on Line 2 below)
I understand that service credit(not more than 12 months)for this leave cannot be established until I have paid my IMRF member
contributions in an amount e Ito the approximate contributions I would have made if actively employed during the leave of absence,plus
interest(if applicable).
MEMBER SIGNATURE DATE
- W,`- . 4 /0 -- / o — 03 -- —
APPLICATION WILL NOT BE PROCESSED WITHOUT AUTHORIZED AGENT AND BOARD CERTIFICATION
CERTIFICATION BY AUTHORIZED AGENT
' lify that(1) I have calculated the estimated employer cost of the above member's leave, (2) I have advised the governing body of the
,unt of such cost and(3)that it will be paid through future monthly contributions.
1. AVERAGE MONTHLY EARNINGS . . ff^^ ,r r ,:: c,. t-
(Determine the monthly average by dividing by 12 the IMRF reported earnings 4 Mz; .. <<
for the 12 months prior to the leave) $ ` �! 1 '' F S, '=1 r
•
2. NUMBER OF MONTHS OF LEAVE(LIMITED TO 12 MONTHS) lit .000
i;x:
—3. TOTAL ESTIMATED EARNINGS THAT WOULD HAVE BEEN PAID S I y ,i..�,
DURING THE LEAVE OF ABSENCE(LINE 1 TIMES LINE 2) C.? � g �.-��— ;� •
9 '!
•4. AVERAGE EMPLOYER COST RATE (LINE 3 TIMES 1190) s .
I —X 11.00% y 'A* r;r
5. ESTIMATED COST OF THIS LEAVE TO EMPLOYER $ 1 0 11 'f/ / ,,,A*" , lt;Z', t 4 Z:IT,
4 .,A
6. ESTIMATED/EXACT EARNINGS TO BE REPORTED WHEN THE EMPLOYEE MONTH IN WHICH EARNINGS AMOU /� 3 3
RETURNS TO WORK (see bottom of previous page) WILL BE REPORTED Dec....„ $ (,�/��(�7 —
AUTHORIZED AGENT SIGNATURE DATE tYJ(�
CERTIFICATION BY CLERK OR SECRETARY OF GOVERNING BODY
I certify that at a regular or special meeting held on S-/!1 'DY , the �y ii ��E 'S
DATE O EMPL ER
Governing Body�approved the leave of absence stated herein and the estimated employer cost as herein determined.
SIGNATU E late' - taen-u/ CLERKARBeeRETAPIY i DATE
— — 43-ld D{
Illinois Municipal Retirement Fund
Suite 500, 2211 York Road, Oak Brook Illinois 60523-2337
Service Representatives 1-800/ASK-IMRF(1-800-275-4673)
www.imrf.org
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