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. . <br /> lLLINOIS MUNICIPAL RETIREMENT FUND <br /> 100 South Wacker Drive -Chicago, Illinois 60506 312/346-6722 <br /> � � OMITTED SERVlCE CREDIT AUTHORfZATION <br /> (See instructions on reverse side} - <br /> Name oi Applicant Social Security Number <br /> � � �. 33s=s -vy� 8' <br /> Address Of J4pplicant Street or Route City,State,Zip Code <br /> S t C . L o C u S t l��c��,�r )L !o-�s..� � <br /> Name oi Current Retirement System Current Position Date began Participation in <br /> T�� � � ` s e e� ��r Current System Sv n� � 1 � � D <br /> Empbyer for Whom Service Was Rendered O itted position Employer Number(State SSA No. <br /> �� 0 �� e at(Jc'' � � �;�. u�'Cl�e•- C' Pr 69-033 3 3� 6 <br /> OPTIONAL:Anticipated retiremerit date , <br /> �E!??!�:CATlQN BY al!THrJRIZ.aT:G":;�E�sT <br /> I certify that the folbwing statement oi earnings for the above applicant are in agreement with the governmental unit's <br /> payroll records and represents the entfre quallfying employment perlod determined by the governing body. <br />� Months of Creditabfe Serv1 <br /> ce Months oi Creditable Service <br /> Calendar With Without Calendar With Without <br /> Year Earnin s Earnin s Earnin s' Year Earnin s Earnin s Earnin s' <br /> [ (o�U, � <br /> �` �34 <br /> � °►� 3 �,y3 � <br /> 'SE-(seasonal leave explained on reverse side) <br /> DATE SIGNATURE OF AUTHORIZED AGENT <br /> RESOLUTION BY GOVERNING 60DY <br /> WHE REAS,the applicant named herein fa Uie per'iod indicated above rotalinp,�months should have been but was not reported to the <br /> Illinas Muniapal Retirement Fund for membership. /E <br /> RESOLVED,that it is the finding of this ���t`� (-�� �� n C � f thar. <br /> . MANE OF(ipVEqHIMG 90DV <br /> 1.The appliqnt worked in a posiDon whith qualified him a her fa membership in IMRF durinp the years and months shown above. <br /> 2.None o1 the service ot the appl�qnt durinp these years and months was in a probationary posit�an of four months or less. <br /> 3.The applipnt is currently empbyed in a qualifying posioon under IMRF a system that has reoprocity with IMRF. <br /> FUR7HER RESOLVED,that the poverninp body aprees w acoept the oblipanon due IMRF fw the vm�tted service employer convibutions payable <br /> through tutiire employer eflnvibu0on rates znd to xcept tM charpes 1rv rmployer ar.a emplo�s��!security ta,es il such taxes hav�not�en pa�d e�L�e <br /> omitted service earninps. � <br /> FURTHER RESOLVED,that the author¢ed apent is hereby authorized and directed to file a een�ie�d copy ot this resolution and alI other pertinent <br /> torms and doaments with the Ilhnois Munidpat Retirement Fund. <br /> CERTIFICATION BY CLERK OR SECRETARY OF GOVF9�NING BODY <br /> �. .the of <br /> MiwE CLENc OR SECRET�qr <br /> .,do hereby certity that I am the keeper of us <br /> MA11E OF OOVERMYEMTAL UMR " <br /> records and that the fae9oinp is a we and correa oopy of a resoluoon duly adopted by its poveminp body a;ameeong held on the day of <br /> ,19 <br /> pATE GIERK OR SEGRETARv i1GMATi41E I� <br /> CERTIFICATION BY APPLICANT <br /> I tully understand that under the Illinois Pension Code I have the right to estab�ish the entire q�calH�ing period.This is to certify that I was <br /> employed and received the above eamings hom the above govemmental unit hom through <br /> and;that I�agree,a� disagree(please send letter of explanation)with the period approvP�S.r the govemmental uniYs goveming body. <br /> DATE SIGK-:?JFE JF AFPUCANT ) <br /> - -- - - - --�� <br /> IMRF FORM 6�(R=V 3ie8) ' -- <br />