02-214 • JUNE 12, 2002 - VOLUME LXVII
IMRF BENEFIT PROTECTION LEAVE Resolution No. 02-214
R IMRF Form 6.32 (6/99)
INSTRUCTIONS ON REVERSE
PLEASE PRINT OR TYPE
MEMBER'S LAST NAME FIRST MIDDLE INITIAL SOCIAL SECURITY NUMBER
BENNETT DAVID C
STREET(MAILING)ADDRESS CITY,STATE AND ZIP
ELGIN IL 60123
CURRENT POSITION MEMBER'S TELEPHONE NUMBER
EQUIPMENT OPERATOR — STREETS
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 5/16/01 and ending 6/25/01
DATE DATE
for a total of 1 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-
ions I an am.. eq . to the .•.roximate contributions I would have made if actively employed during the leave of absence,plus interest.
MEMBE• SI ATUREE DATE
CERTIFICATION BY AUTHORIZED AGENT
I certify that(1)I have calculated the estimated employer cost of the above member's leave,(2)1 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 s„ #; '.v
(Determine the monthly average by dividing by 12 the IMRF reported earnings 3961.83 '
for the 12 months prior to the leave) $
2. NUMBER OF MONTHS LEAVE(LIMITED TO 12 MONTHS) �; 's.✓
1 a 4 sx
3. TOTAL ESTIMATED EARNINGS THAT WOULD HAVE BEEN PAID
DURING THE LEAVE OF ABSENCE(LINE 1 TIMES LINE 2) 3961 r 83 F;
4. AVERAGE EMPLOYER COST RATE (LINE 3 TIMES 11%) 'o 'v�S
X11.00% •
S. ESTIMATED COST OF THIS LEAVE TO EMPLOYER
435.80 -may
J rr«'sue e:?fir? Pa l
AUTHORIZED AGENT SIGNAT RE DATE
CERTIFICATION BY CLERK OR SECRETARY OF GOVERNING BODY
I certify that at a regular or special meeting held on June 12, 200 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 E CLERK OR SECRETARY DATE
Dolonna Mecum 6/13/02
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)8EIWASK-IMRF