Section 6 - IMRF

OUT-OF-STATE CREDIT AUTHORIZATION
IMRF Form 6.33 (Rev. 06/09)
Exhibit 6Z
Page 1 of 2
INSTRUCTIONS AND REQUIREMENTS ON REVERSE SIDE
PLEASE PRINT OR TYPE
Member’s First Name Middle Intial Last Name Social Security Number
Jane M. Rowe 321-00-0001
Member Mailing Address City, State, and ZIP Current Position
123 Main Street Anywhere, IL 60000 Deputy City Manager
Current Employer Name
Employer Number
City of Anywhere 09999
Certification by Member
City of Sterling
I certify that I was an employee of _____________________________________________________________________________,
Name of Local Government
_______________________________________from Colorado ____________________________to July 1, 1998 _______________________________
July 1, 2003
Name of State Date Date
in the position(s) of _________________________________________________________________________________________
Accounting Manager
such service having been covered under ________________________________________________________________________
Colorado Municipal Employees Fund
Name of Public Employee Pension System
whose address is ___________________________________________________________________________________________
3764 Aspen Avenue Sterling Colorado 80000
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.
_______________________________ August 18, 2009 ___________________________________ _______________________________
000-888-5555
Date Member’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____________________ August 15, 2009 , the __________________________________________
City Council
Date
Name of Governing Body
of ________________________________________________ City of Anywhere
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 _____________________ 7/1/1998 to ____________________ 7/1/2003
(not to exceed 120
Date
Date
months for the above named member).
________________________ August 1, 2009
_________________________________ Clerk
___________________________________________
Date Clerk or Secretary Signature
Illinois Municipal Retirement Fund
2211 York Road, Suite 500, Oak Brook Illinois 60523-2374, 630/368-1010
Member Services Representatives 1-800/ASK-IMRF (1-800-275-4673)
IMRF Form 6.33 (Rev. 06/09)