1993-012831 Acacia Terrace.
ME OF BIRTH TWPMONE NO.
2/28/37 1(
p� ter ( 708 9
M OF Assembly Retirement
SvGtem
(PLOVER FOR WHOM SERVICE WAS RENDERED
Village of Buffalo Grove
6
P08ll-M ` DATE PARTICIPATION OEM
IN CURRENT SYS IM! _
POSITION I EMPLOYER NUMBER (sTA
.,e Collector -b-B-21
��rw��w��wu rev ��rAUw�rw �wtu�
I certify that the following statement of earnings for the above member are in agreement with the gmrnrr*nW unit's
payroll records and represents the entire qualifying employment period determined by the governing body. '
CALENDAR
YEAR
EARNINGS
Moms OF CREIxr"LE SERVICE
CALENDAR
YEAR
EARNINGS
mom" OF CREW"LE SERVICE
WITH
EARNINGS
WITHOUT
EARNINGS'
WITH
EARNINGS
WITHOUT
EAiWNrGe
1972
1,670.00
1
1974
5,679.96
t 12
1 78
1975
6,673.78
12
12/7/92 'SE - (one" Maw explained on reverse side) `%AA."
tirF SNUTATURE OF AUTh . A[aEM
RESOLt1TION BY GOVERNING BODY
WHEREAS, the member should have been but was not repored to ter Mtals Municipal Retkwmrrl Fund fora perlod of 78 nordhs.
WHEREAS, employer contributions for the on*W servioe are payable to Nkwb Municipal Retireernt Fund through an adluslnenl to future employer
OoMflbNllon rtles.
RESOLVED, A is the firm" of this Villsqg —of Suf f zlc 6r.e ue thn:
pme of ooveRNea wort
1. The member worked in an tarots MunkApal Ratksmera Furl gwNykg podUn durkp the bears and .=0 set WIft above.
2. The member is arnently employed in an aARF qua" po dion or a system OW has rodprocay w1h MRF.
FURTHER RESOLVED. dnt the authorized apeant is dkeded lo Ale a a@AW*d copy of Ulis nookdIon and any pwUnera forms and documents with Ale
Mkrols Municipal Retkemsra Fund.
CERTIFICATION BY CLERK OR SECRETARY OF GOVERNING BODY
I, Janet M. Sirabian ,the Villas?P C1Prk of
IMME culAXONSOMMW
i11agP of R>,ffnln G,- IM- Coojr Jr, 1,2k, GetjffE4!E,8,, 11 •dohneWcaAAyVWIamrie keeper atNo
NIME OF OOVERNMEWAL UNT
records and that the foregoN In a true and coned Copy of a raokmon duly adopted by As. Aovernklp body at a nteetln . held en the _ 4th Ay of
Tanner >> .19 Q4
VI��gP �'.� PYk ,i
GATE exarek OR sealTMM
CERTIRCAT10N BY MEMBER
I fully Understand that w4erthe Illinois Pension Code 1 have the tight to establish the entire quali irtp poriod. This is b f»rtily that I was
employed and received the above eamin(Is from Ow above governmental unit from s/1 / 7
that I�sgree, or p disagree (please send letter of explanation) with tlw period verfi the gove a irtp body.
awe- % /9S Z
DATE I M&W-URE OF MEMBER
IMRF Form 6.05 (Rev. 7/91)
OMITTED SERVICE CREDIT VERIFICATION
101181 RUCT10Ni FOR USE
WHEN TO USE THIS FORM:
If the entire omitted period falls within the current calendar year or can be reported prior to February 15 of the following year, You
may use IMRF Form 3.20, "Employers Report of Adjustments to IMRF Earnings.' N the entire omitted period does not fail within the
current year, you should use this form.
REQUIREMENTS FOR OMITTED SERVICE CREDIT.
1. The service was rendered by a member in a position qualified for IMRF membership. Do not apply for omitted service credit for
members who are now in qualifying positions but ask for credit for service they previously rendered in non- qualillying positions. if
the member previously worked in a nonqualifying position that was properly classified ss such, the member and position should
not now be reclassified as qualifying.
2. The service was not previously reported to IMRF. The earnings for this period may or may not have been reported for Sodel
Security.
3. The service was rendered by the member after the date the governmental unit joined IMRF. Use Form 6.07, "Application for Prior
Service Credit," for eligible service rendered prior to the date the governmental unit joined IMRF. Refer to Form 5.07 for specific
requirements.
4. This form must be received by IMRF while the member in currently participating in IMRF or another retirement system oovsred
by the Illinois Retirement Systems Reciprocal Act.
S. The omitted service resolution on the front of this form is adopted by the governing body, certified by the Clark or secretary.
S. The form is certified by the Authorized Agent and member.
7. The member pays IMRF contributions on the omitted earnings. Interest is calculated on the Contribution from the and of the
omitted period through December 31 st of the year preceding the current year.
EARNINGS:
Enter in the space provided on this form the annual gross earnings for the entire qualifying period, not previously reported for IMRF
coverage. Service credit can only be granted in the month a member worked and received payment. An exception to this rule will
be made for members in seasonal positions or members paid irregularly such as elected officials. EXAMPLE: A member hired on
January 15, but first paid in February would not be entitled to service credit for January.
SEASONAL LEAVE:
The member may receive service credit for the periods without earnings provided the member:
1. was employed in a seasonal position,
2. had six consecutive months of earnings within a 12 -month period,
3. remained in an employment relationship during the seasonal leave period and the member received earnings after the leave
period.
If the member did not receive earnings after the seasonal leave period, please explain why and we will determine whether service
should be granted.
SOCIAL SECURITY WAGE ADJUSTMENTS:
If Social Security wages were also omitted, see Section 4 of the Manual for Authorized Agents.
PAYMENT OF CONTRIBUTIONS AND INTEREST:
IMRF will mail to the member a Past Service Payment Schedule which offers two payment plan options for establishing the past
service. Option 1 is the Lump Sum Payment Plan and Option 2 is the Unit Payment Plan. The Lump Sum Payment allows members
to pay the total cost with a single payment and purchase all past service at once. The Unit Payment Plan allows members to
purchase one or more months at a time. Members may pay as often as they like, buying back credit from the latest month to the
earliest month of eligible service. However, they may not buy more months than indicated on the Past Service Payment Schedule.
Note: Members who have terminated IMRF participation can make one payment only for past service.
INFORMATION FOR MEMBERS UNDER THE RECIPROCAL ACT:
A minimum of 12 months of service credit with any single reciprocal pension system is required by the Illinois Retirement Systems
Reciprocal Act. Smaller amounts of service with any one system will not be counted in the computation of a reciprocal pension. A
list of the 13 systems covered by the Act are listed in Section 5 of the Manual for Authorized Agents. Local police and fire pension
funds are not covered by the Act.
PENSION ESTIMATES:
Members who want to know how the omitted service will affect their pension, should wait until they receive the Past Service
Payment Schedule and decide how many months of service to purchase. Then they can write or, call their current system for a
pension estimate.
EMPLOYER'S COST:
The governmental unit's contribution for omitted service is made through future contribution rates. Therefore, a separate payment is
not required. The actuary will take the omitted service into account when annually determining the employer contribution rate. This
is the rate shown on IMRF Form 3.10, "Monthly Deposit Report."
IMRF Form 6.05 (Rev. 7/91)