02-215 VOLUME LXVII JUNE 12 , 2002
M IMRF BENEFIT PROTECTION LEAVE Resolution No. 02-215
R IMRF Form 6.32 (6/99)
INSTRUCTIONS ON REVERSE
PLEA SE PRINT OR TYPE
MEMBER'S LAST NAME FIRST MIDDLE INITIAL SOCIAL SECURITY NUMBER
MOGLER THOMAS R
STREET(MAILING)ADDRESS CITY.STATE AND ZIP
ELGIN IL 60123
CURRENT POSITION MEMBER'S TELEPHONE NUMBER
UTILITY WORKER — STREETS
EMPLOYER NAME EMPLOYER IMRF I.D.NUMBER
CITY OF ELG1Ti .
CERTIFICATION BY MEMBER
I certify that I will be(or have been)on leave of absence beginning 10/17/01 and ending 1/1/02
DATE DATE
for a total of 3 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-
tions in an amount equal to the approximate contributions I would have made if actively employed during the leave of absence,plus interest
MEMBEB-S1GNA-W•RE— � . A DATE
crV
CERTIFICATION BY AUTHORIZED AGENT
I certify that(1)I have calculated the estimated employer cost of the above member's leave,(2)I 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 '
(Determine the monthly average by dividing by 12 the IMRF reported earnings ram ; ;zit
for the 12 months prior to the leave) $ 3853.66
2. NUMBER OF MONTHS LEAVE(LIMITED TO 12 MONTHS) < /
3
3. TOTAL ESTIMATED EARNINGS THAT WOULD HAVE BEEN PAID S K x z
DURING THE LEAVE OF ABSENCE(LINE 1 TIMES LINE 2) 11560.08 inf
4. AVERAGE EMPLOYER COST RATE (LINE 3 TIMES 11%) o �
X 11.00/o x' �
`L S'k4F v, /• 5�
•
5. ESTIMATED COST OF THIS LEAVE TO EMPLOYER
1271.61 = %