04-138 t R OUT-OF-STATE CREDIT AUTHORIZATION Resolution No. 04-138
IMRF Form 6.33(Rev. 6/99)
INSTRUC71ONS AND REQUIREMENTS ON REVERSE SIDE
PLEASE PRINT OR TYPE
Members First Name Middle Intel Last Name Social Number
MIRK H OOt U4 Et-Of 353• 2- 1158
Member Mailing Address City,State,and ZIP Current Positlien
207 1>UKRI OGt a li t Qcc,t= E.Outset= .L (sou% AchtSTAW CAIEFP1rRNr OPERATOQ
Current Employer Name Employer Number
Ctz�C O( tELEntmr lt.t,IMOls Q> 3391
Certification by Member
I certify that l was an employee of k E O K U K 11 U ht i C l PAL ''0 I 1
1 A T E R WORK S
Name of Local Government
t owA from MAY 211 zool to APRtr`. It ZaoZ
Name of State Date date
in the position(s)of ISSISTAMT SUPP-R414�rTr 4OAN.!
ch
su service having been covered under IOWA?U Q 1,%G E M Pt,o Y C E S' )Z PST t R It t1 F K T c`>'s T P M
T] r Name of Public Pension System
whose address is l 4Ot REcttsTpf () Rive Des ( IOu .4rS lowA S030C.1 tl7
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. }�
11ARC t 2'ol ZOOti ke VJ isH7- i31 - 6753
Date Member's Sig Member's Daytime Telephone No
Certification by Clerk or Secretary of Governing Body
I certify that a regular or special meeting held on May 76;,:, 2 n n 4the C i i-y C n i l n c i 1
Date- Name of Governing Body
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 May 21 , 2 0 01 to Ap r i 1 11, 2 0 0 anot to exceed 120
Date Date
months for the above named member).
June 1 , 2004 Dolonna Mecum �2G[,tr-�
Date Clerk or Secretary Signature
Illinois Municipal Retirement Fund
2211 York Road.Suite 500.Oak Brook Illinois 60523-2374. 6301368-1010
Service Representatives 800/ASK-IMRF (1-800-275-4673)
IMRF Form 6.33 (Rev.6/99)
.(OF Etc.
%; g City of Elgin Agenda Item No.
t9TEDFE$ E
L
May 7, 2004 w E0! W p
�r1 {. is
W pi
TO: Mayor and Members of the City Council
FINANCIALLY STABLE CITY GOVE RNMENT
EFFIC TENT SERVICES.
AND OUALITY INFRASTRUCTURE
FROM: David M. Dorgan, City Manager 1
Femi Folarin, Assistant City Manager
SUBJECT: Prior Service Authorization
PURPOSE
The purpose of this memorandum is to provide the Mayor and members of City Council with
information to consider approval of the purchase of out of state service by employee, Mark
Donnelly, current Assistant Chief Plant Operator for the City of Elgin.
RECOMMENDATION
elik It is recommended that the City Council approve the purchase of prior service credit for Mark
Donnelly.
BACKGROUND
Mark Donnelly worked for 11 months for Keokuk Municipal Water Works. He now desires to
purchase his months of service with the Iowa Public Employees' Retirement System plan. The
City has, in the past, allowed employees with previous service credit the opportunity to purchase
such service.
COMMUNITY GROUPS/INTERESTED PERSONS CONTACTED
None.
0'3.'6 FINANCIAL IMPACT
Should Mr. Donnelly elect to purchase the past service, the cost to the City would be made
through future contribution rates. Therefore, a separate payment is not required at this time. The
IMRF actuary will take the out of state service into account when annually determining the
City's employer contribution rate.
rook Prior Service Authorization
May 12, 2004
Page 2
LEGAL IMPACT
VA4ty
None.
ALTERNATIVES
1. Approve the request of Mark Donnelly.
2. Deny the request.
Respectfully submitted for Council consideration.
FF/hhp
Attachment
r
eft.
M OUT-OF-ST T CREDIT AUTHORIZATION
FIMRF Form 6.33 (Re • 9)
INSTRUCTIONS AND REQUIREMENTS ON REVERSE SIDE
PLEASE PRINT OR TYPE
Member's First Name Middle Intial Last Name Social Security Number
PENGYI LI 189 70 1357
Member Mailing Address City,State,and ZIP Current Position
1226 HAC[tBERRY CT ELGIN IL 60120 GIS COORDINATOR
Current Employer Name Employer Number
CITY OF ELGIN 03347
•
Certification by Member
I certify that I was an employee of Sarasota Counter
Name of Local Government
_Florida - from 116/1.994. to 7/1996
Name of State Date Date
in the position(s)of Planner/Planning Department
such service having been covered under Sarasota County Retjrent Platt ________________
Name of Public Employee Pension System
whose address is___—__.166a_ung-.Ling Boulea,rd,_.Sar-asota� FL_-43236--
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. y
`�
D3/02/II4
-.
_--- _ 847 289 9506----
Date '` m er's Signature Member's Daytime Telephone No.
Certification by Clerk or Secretary of Governing Body
I certify that a regular or special meeting held on_Q3-3L-14 ,the ____City__Cnunei L
Date Name of Governing Body
of ___fit £_$1 - —__ __authorized the granting of service credits for out-of-state service with
Name ofCovemmental Unit
the out-of-state governmental unit named herein from 06-1994 to 07-1996 (not to exceed 120
Date Date
months for the above named member).
9A941/1-v•-i-k_-
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)
IMRF Form 6.33 (Rev.6/99)