ILLUSTRATION A - DOI Information Request for an Officer's Creditable Service Transfer

Current through Register Vol. 46, No. 15, April 8, 2022

Please Forward This Request To:

Illinois Department of Insurance

Public Employee Pension Division

320 West Washington Street

Springfield, Illinois 62767-0001

Within 30 working days after the Illinois Department of Insurance receives this request the Department will provide the current pension fund with the actuarial accrued liability, and reserve, amounts to be used in determining the true cost of transferring creditable service time.

1. Officer's Name: ______________________________________________
2. SS#: ______________________________________________________
3. D.O.B.: _____________________
4. Benefit Tier*: ___Tier 1___ ____Tier 2____________________________
5. Entry Date into Current Fund: ____________________________________
6. Date Current Pension Fund Received Request for Transfer of Creditable Service:

_____________________________________________________________

7. Officer's Age at the Time the Current Pension Fund Receives the Request for Transfer of Creditable Service:

_____________________________________________________________

8. Current Annual Salary of the Officer as of the Date the Current Pension Fund Received the Request for Transfer of Creditable Service:

_____________________________________________________________

9. Years, Months and Days of Creditable Service Time in Current Fund to Date Current Pension Fund Receives Request for Transfer of Creditable Service:

_____________________________________________________________

10. Date(s) of Any Service Breaks from Current Fund Where Service Credit Was Not Given: ________________________________________________________
11. Entry Date into Prior Pension Fund(s): ____________________________
12. Date of Termination from Prior Pension Fund(s): ____________________
13. Years, Months and Days of Creditable Service Time Being Transferred from Prior Pension Fund(s): ____________________________________________
14. Date(s) of Any Service Breaks from Prior Pension Fund Where Service Credit Was Not Given: ________________________________________________
15. Current Pension Fund Contact Person, Mailing Address and Telephone Number:

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

16. Pension Fund Trustee Name, Signature and Date:

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

* Check the Tier 1 box for a participant who first became a police officer under Article 3 before January 1, 2011, regardless of whether the participant has received a refund. Check the Tier 2 box for a participant who first became a police officer under Article 3 on or after January 1, 2011. (See 40 ILCS 5/3-111(d).)

Notes

Amended at 40 Ill. Reg. 14751, effective 10/17/2016

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