Section 6 - IMRF

IMRF Transfer to state employees RETIREMENT SYSTEM
EXHIBIT 6WW
(SERS Alternative Retirement Formula Plan)
Under Public Act 95-0530
IMRF Form 6.92 (08/2007)
SERS Information
Telephone ( 000 )___________________________________ 123-4567 Alternate Phone ( 000 )_ ______________________
789-1234
Contact Person _ ____________________________________ Henry Roe
Title _ ___________________________________________
Administrator
E-mail Address _ _____________________________________________________________________________________
Hroe@sers.org
Indicate how SERS wishes to receive
the member and employer credits: XX n Check n Automated Clearing House (ACH) transfer
If ACH, complete the following:
ABA/Routing Transit # ____________________________________________ n Checking n Savings
Bank Account # ____________________________________________________________________________________
Your Information
Full Name ________________________________________________________________________________________
Doe John J
Last First M.I.
Current SERS position:
n X State policeman
n Conservation police officer
n Other_______________________________
n Controlled substance inspector
n Investigator for Secretary of State
789-10-3456 johndoe@verizon.com
Social Security # _ _________________________ Email Address: _________________________________________
Home Address ____________________________________________________________________________________
456 Greem Street 333 Anywhere IL 60000
Street Address Apt. # City, State, Zip
Telephone ( 000 )______________________________________ 123 3333 Alternate Phone ( 000 )____________________
456-3214
Forfeited/Refunded IMRF Service Credit
Do you have any refunded IMRF SLEP service credit you want to reinstate and transfer to SERS n X No n Yes
If yes, complete the following:
If you previously used a different name with IMRF, please indicate:____________________________________________
Year(s) in which you received your refund check(s):________________________________________________________
IMRF Coverage Period(s) _ ___________________________________________________________________________
Please note: If you reinstate your forfeited IMRF SLEP service credit at the reduced interest rate of 6%, you must transfer
all of the service to the SERS Alternative Formula Annuity Plan.
___________________________________________________ September _____________________________________
10, 2007
SERS Member Signature
Date
Mail this form to IMRF, 2211 York Road, Suite 500, Oak Brook IL 60523 or fax to 630-706-4289
For IMRF Use Only: IMRF PARTICIPATION INFORMATION IMRF FEIN # 36-6001368
Coverage Period
Transferred
Service
Amount Yrs. Mos.
Coverage Period
Transferred
Service
Amount Yrs. Mos.
Total Transfer
Amount $
Total Member
Contributions $
IMRF Form 6.92 (08/2007)
Tax-deferred
Portion $
Total Member
Interest $
Previously-taxed
Portion $
Employer Contributions
and interest $