Section 6 - IMRF

APPLICATION BY A MEMBER OF THE GENERAL ASSEMBLY
FOR SERVICE CREDIT AS AN ELECTED OFFICIAL
IMRF Form 6.34 (Rev. 6/98)
Exhibit 6AA
PLEASE PRINT OR TYPE
MEMBER’S LAST NAME FIRST MIDDLE INITIAL SOCIAL SECURITY NUMBER
MEMBER’S ADDRESS
Doe Robert J. 000-02-3456
TITLE OF ELECTED POSITION
123 Spruce Street Alderman
EMPLOYER FOR WHOM SERVICE WAS RENDERED
EMPLOYER IMRF I.D. NUMBER
City of Anywhere 9 9 9 9
CERTIFICATION BY AUTHORIZED AGENT
I certify that earnings, for the above IMRF member, shown in the following statement are in agreement with the governmental
unit’s payroll records.
MONTHS OF SERVICE CREDIT
MONTHS OF SERVICE CREDIT
CALENDAR WITH WITHOUT CALENDAR WITH WITHOUT
YEAR EARNINGS EARNINGS EARNINGS* YEAR EARNINGS EARNINGS EARNINGS*
1993 800 8
1994 1,200 12
1995 1,200 12
1996 1,200 12
1997 1,200 12
1998 1,200 12
1999 1,200 12
2000 400 4
*PI - (Paid Irregularly)
I further certify that,
(1) The earnings reported above are the total amount paid to the official named herein whose qualifying position and
service was rendered as a
❑ Full time elected Official ❑ Part time elected Official ❑ Governing Body Member
( A resolution must be on file with IMRF affirming the above elected positioni ndicated qualified the official for
membership.)
(2) The member is entitled to service for the number of months indicated above as without earnings (PI). These are
months during which the member was in office but received no pay because payment was made at various intervals.
____________________________________________________
X
August 18, 2006
________________________________________
Signature of Authorized Agent
Date
CERTIFICATION BY GENERAL ASSEMBLY MEMBER
I certify that my service as an elected official was in a position which qualified for membership during the above period.
I hereby request a statement of the amount required to establish service credit on my earnings as stated above, which I affirm
to be a correct and true statement.
____________________________________________________
Signature of General Assembly Member
August 18, 2006
_______________________________________
Date
IMRF Form 6.34 (Rev. 6/98)
Illinois Municipal Retirement Fund
Suite 500, 2211 York Road, Oak Brook Illinois 60523-2337
Service Representatives 800/ASK-IMRF