Imrf Form 5 20 – Fill Out and Use This PDF

1. File this form one month before your retirement date.

• Include required documents (copies not originals) with your application.

DATE FORM MAILED/FAXED TO IMRF

Print your Social Security number on all documents you attach to this

DOCUMENTS INCLUDED:

form.

(Check box if mailed/faxed with form.

•

Married or in a civil union for at least one year: your Birth

Fill in date next to item if mailed/faxed

later.)

Certificate and your Marriage Certificate or Civil Union Certificate.

•

Divorced: your Birth Certificate and your Judgment of Dissolution

o Birth Certificate

o Marriage Certificate

of Marriage/Civil Union (Divorce Decree) - first page and Judge’s

o Civil Union Certificate

signature page only.

•

o Judgment of Dissolution of

Widowed, never married, or never in a civil union: your

Marriage/Civil Union (Divorce

Birth Certificate.

Decree) - first page and Judge’s

• If you do not have all the required documents, submit your completed

signature page only.

application without them. Send any missing documents to IMRF as soon

as possible.

2. This form contains Form 5.20 and Form 1199:

FORM 5.20/1199 COMPLETION:

Form 5.20 Application for IMRF Pension and Form 1199 Application

(Check these key boxes to ensure you

have completed the paper form fully.*)

for Direct Deposit. Please complete both Form 5.20 and Form 1199 and

o Member information provided

return both forms together at the same time.*

o Spouse/marital status informa-

• Be sure to sign both forms.

tion provided, if applicable

• Direct Deposit of your monthly benefit payment is mandatory.

o Reciprocal service information

provided, if applicable

Your payment must be directly deposited into your checking, savings

o Both forms signed by Member

or a brokerage account.

o Direct Deposit information

3. Next steps:

provided

ADDITIONAL FORMS SUBMITTED:

• After we receive your application, you will receive an IMRF

(Check box and fill in date next to item if

Retirement Packet, which contains:

form was mailed, faxed, or electronically

• Insights for Retiring Members booklet

submitted via Member Access.)

• IMRF Form 6.11A, “Designation of Beneficiary for Annuitants”

o IMRF Form 6.11A

(Return immediately.*)

o Form W4-P

• IMRF Form W4-P, “Withholding Certificate for Pension or Annuity

o Health Insurance

Payments” (Return immediately.*)

Continuation Form

• Health Insurance Continuation Form (paper format only)

Be sure to create a

• Self-addressed return envelope

Member Access

*NOTE: You can submit Forms 5.20, 1199, 6.11A and W4-P online via

account so you can

Member Access. See following page for more information regarding

have 24/7 access

IMRF’s Member Access.

to your

Illinois Municipal Retirement Fund

IMRF records!

2211 York Road, Suite 500, Oak Brook, Illinois 60523-2337

Member Services Representatives: 1-800-ASK-IMRF (1-800-275-4673) FAX: 630-706-4289

www.imrf.org

www.imrf.org/myimrf

IMRF Form 5.20 (Rev. 06/2012)

APPLICATION FOR IMRF PENSION

You can complete and submit this form

IMRF Form 5.20 (Rev. 06/2012)

electronically via Member Access. You can print

PLEASE PRINT OR TYPE

paper forms from www.imrf.org.

MEMBER’S FIRST NAME

MIDDLE INITIAL

LAST

JR., SR., II, ETC.

SOCIAL SECURITY NUMBER

_______________ - ________ - _______________

MEMBER’S MAILING ADDRESS

CITY

STATE

ZIP+4

GENDER

MALE

FEMALE

MEMBER’S BIRTH DATE (MM/DD/YY)

DAYTIME TELEPHONE NO.

LAST DAY OF WORK (MM/DD/YY)

MARITAL STATUS

GENDER OF SPOUSE

NEVER MARRIED

MARRIED

CIVIL UNION

MALE

FEMALE

DIVORCED

WIDOWED

SPOUSE’S FIRST NAME

MIDDLE INITIAL

LAST

JR., SR., II, ETC.

SPOUSE’S SOCIAL SECURITY NUMBER

_______________ - ________ - _______________

DATE OF MARRIAGE/CIVIL UNION (MM/DD/YY)

SPOUSE’S DATE OF BIRTH (MM/DD/YY)

DATES

NAME OF SYSTEM

FROM

TO

IF YOU WILL RETIRE UNDER IMRF EARLY RETIREMENT INCENTIVE, SUBMIT FORM 5.21, “NOTICE TO RETIRE UNDER ERI.”

INDICATE THE YEARS / MONTHS YOU WISH TO PURCHASE:

_________ YEARS

________ MONTHS

I CERTIFY THAT THE ABOVE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.

X

MEMBER’S SIGNATURE (WRITE; DO NOT PRINT OR TYPE)

DATE