10-83 • IMRF BENEFIT PROTECTION LEAVE
Resolution No. 10-83
R IMRF Form 6.32 (Rev. 02/08)
F * Avoid delays—read the instructions before completing this form
PLEASE PRINT OR TYPE
3ER'S FIRST NAME MIDDLE INITIAL LAST (JR.SR.II,ETC) SOCIAL SECURITY NUMBER
•
(^ .o wg. 359 64 1919
STREET(MAILING)ADDRESS CITY,STATE AND ZIP
19 '1,--‘ Ctu 4__t i,� , x l (.00c3 - 19a-7
CURRENT POSITION MEMBER'S TELEPHONE NUMBER
U.-Et y a t° l f o Lid 4 1 ) b`l S a5-w„
EMPLOYER NAME EMPLOYER IMRF 1.D.NUMBER
Gf t- oS— iv■ •
•
CERTIFICATION BY MEMBER (If the end date is unknown or in the future)
I.certify that I will be(or have been)on leave of absence beginning 4. /a S la o and ending l 1 777T
DATE DATE
for a total of C 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 equal to the approximate contributions I would have made if actively employed during the leave of absence,plus
interest(if applicable).
MEMBER SIGNATURE DATE
td /6 / aofJet
CERTIFICATION BY AUTHORIZED AGENT
`ify that(1)I have calculated the estimated employer cost of the above member's leave,(2)t have advised the governing body of the
ant of such cost and(3)that it will be paid through future monthly contributions.
1. AVERAGE MONTHLY EARNINGS
(Determine the monthy average by dividing by 12 the IMRF reported earnings rA
for the 12 months prior to the leave) $ ` 3_I (q C')
2. NUMBER OF MONTHS OF LEAVE(LIMITED TO 12 MONTHS) CJ
3. TOTAL ESTIMATED EARNINGS THAT WOULD HAVE BEEN PAID $ •
DURING THE LEAVE OF ABSENCE(LINE 1 TIMES LINE 2) 1 5 r SS
4. AVERAGE EMPLOYER COST RATE (LINE 3 TIMES 11%1
X11.00% . .
5. ESTIMATED COST OFTHIS LEAVETO EMPLOYER $ jt 4- 55.0r
B. ESTIMATED/EXACT EARNINGS TO BE REPORTED WHEN THE EMPLOYEE MONTH IN WHICH EARNINGS AMOUNT
RETURNSTO WORK (see bottom of previous page) WILL BE REPORTED $
"55.0-5
AUTHOR! ED AGENT SIGNATURE DATE _
L ill) /l o
CERTIFICATION BY CLERK OR SECRETARY OF GOVERNING BODY
I certify that at a regular or special meeting held on April 14, 2010 , the City of Elgin .'s
DATE EMPLOYER
Governing Body approved the leave of absence stated herein and the estimated employer cost as herein determined.
SIGNATURE CLERK OR SECRETARY DATE
Q.NIQ_, t c}vL, City Clerk April 14, 2010
Diane Robertson
Illinois Municipal Retirement Fund
Suite 500, 2211 York Road, Oak Brook Illinois 60523-2337
Member Services Representatives 1-800/ASK-(MRF(1-800-275-4673)
www.imrf.org