Section 6 - IMRF
Section 6 - IMRF
Section 6 - IMRF
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CONVERSION OF REGULAR OR SLEP SERVICE CREDIT<br />
TO ELECTED COUNTY OFFICIAL (ECO) SERVICE CREDIT<br />
For earnings previously reported to <strong>IMRF</strong><br />
<strong>IMRF</strong> Form 6.06 (Rev. 02/08)<br />
Exhibit 6J<br />
Page 3 of 3<br />
Avoid delays—read the instructions on the previous pages before completing this form<br />
PLEASE PRINT OR TYPE – USE BLACK INK<br />
MEMBER’S FIRST NAME MIDDLE INITIAL LAST JR., SR., II, ETC. SOCIAL SECURITY NUMBER<br />
__ __ __ __ __ __ __ __ __<br />
Robert J. Doe 0 0 0 - 0 0 - 0 0 0 0<br />
STREET (MAILING) ADDRESS CITY, STATE AND ZIP + 4<br />
123 Birch Street Anywhere, IL 60000<br />
DATE OF BIRTH TELEPHONE NO. OPTIONAL: ANTICIPATED RETIREMENT DATE<br />
July 14, 1947 (000) 000 -0000<br />
NAME OF CURRENT <strong>IMRF</strong> EMPLOYER<br />
County of Anywhere 0 0 0 0<br />
CURRENT POSITION<br />
<strong>IMRF</strong> EMPLOYER I.D. NUMBER<br />
FIRST DATE OF PARTICIPATION IN ECO PLAN<br />
County Auditor November 3, 1999<br />
NAME OF COUNTY EMPLOYER WHEN YOU ELECTED TO PARTICIPATE IN ECO<br />
Anywhere<br />
PERIOD(S) OF PARTICIPATION (REGULAR SERVICE CREDIT) TO BE CONVERTED<br />
Enter the periods of employment you wish to convert to SLEP service credit. The date you opted into the ECO plan will determine<br />
what periods may be converted.<br />
Refer to item 3 under “Instructions for Completing...” to determine which Regular/SLEP service credit can be converted.<br />
COVERAGE PERIOD OR<br />
NAME OF <strong>IMRF</strong> EMPLOYER(S) TITLE OF OFFICE OR POSITION TERM OF OFFICE<br />
City of Anywhere Accountant 5/6/1987 to 10/31/1999<br />
CERTIFICATION BY MEMBER:<br />
I hereby certify that,<br />
• I have previously participated or currently am participating in <strong>IMRF</strong> under the Elected County Official (ECO) plan and have<br />
submitted <strong>IMRF</strong> Form 6.21, “Election by Elected County Official to Participate in the Elected County Official Plan,” or 6.21B,<br />
“Election by Elected County Official to Participate in the Elected County Official Plan rev. on 1/26/00”<br />
• The service credit (contributions) covering employment periods listed above are currently on record with <strong>IMRF</strong>, and<br />
• I now request that you provide me with the cost to convert this service credit so it may be considered ECO service credit.<br />
x<br />
Signature of Member<br />
August 15, 2012<br />
Date<br />
<strong>IMRF</strong> Form 6.06 (Rev. 02/08)<br />
Illinois Municipal Retirement Fund<br />
2211 York Road, Suite 500, Oak Brook Illinois 60523-2337<br />
Member Services Representatives 1-800-ASK-<strong>IMRF</strong> (1-800-275-4673) 7:30 a.m. to 5:30 p.m.<br />
www.imrf.org