IMRF Forms by Number

Miscellaneous Forms
Form Series No. #1
Form Series No. #2
Form Series No. #3
Form Series No. #5
Form Series No. #6
Form Series No. #7

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BF-20 - Pension Estimate Request (11/10)
BW-60 - Distribution/Rollover Certification (01/10)
BW-6B - Distribution/Rollover Certification for non-spouse beneficiaries (07/10)
BW-60Q-Distribution/Rollover Certification QILDRO (10/02)
W4-P - Withholding Certificate for Pension or Annuity Payments (Can also be submitted via Member Access)
1199 - Direct Deposit Authorization Form (07/07)
VARF - Voluntary Additional Contributions Refund Form (11/10)
QILDRO -Qualified Illinois Domestic Relations Order (QILDRO) Form (7/11)
QILDRO Consent - Consent to Issuance of QILDRO Form (7/11)
QILDRO Court Calculation Order Form (7/11)
Freedom of Information Act Information Request Form/Booklet (08/11)
TR-6 - Application for the issuance of a replacement check for lump sum benefit payments (8/98)
A-19 - Application for transfer of employee contributions to Police Pension Fund (6/04)
Social Security Administration -Form 1945 - Statement Concerning Employment in a Job Not Covered by Social Security (Links to the Social Security website)
A-20 - Application for transfer of employee contributions to Fire Pension Fund (6/04)
Enrollment-Check List: Should this employee be enrolled in IMRF? (04/08)
Participation-Check List for Authorized Agents (7/06)
Retirement -Check List for Authorized Agents (7/07)
Disability -Check List for Authorized Agents (9/07)
Termination -Check List for Authorized Agents (7/06)
Death -Check List for Authorized Agents (7/07)

2.20 - Notice of Appointment of Authorized Agent (08/11)
2.30 - Notice of Election or Appointment of Township Supervisor (08/11)
2.50 - Forms/Publications Request (02/11)
2.80 - Employer Access User ID Form Obsolete, Click here to register for an account
2.90 - Freedom of Information Act Information Request Form (07/11)

3.00 - IMRF Electronic Funds Transfer (EFT) Enrollment Form (5/03)
3.01 - Change Account for Electronic Payments from IMRF (8/06)
3.20 - Employer's Report of Adjustments to IMRF Earnings
Submit adjustments to IMRF earnings via Employer Access

5.10 - Application for Separation Refund (01/10)
5.10B - Previously Taxed Rollover Request (01/08)
5.20 - Application for Retirement Annuity (09/11) **
5.20R - Application for Special Needs (Reversionary) Annuity (05/08)
5.21 - Member's Notice of Intent to Retire Under ERI (12.10)
5.30 - Application for Death Benefitt (07/11)
5.40 - Member's Application for Disability Benefits (03/2011)
5.41 - Employer Statement - Disability Claim (06/09)
5.42 - Physician Statement - Disability Claim (05/11)
(Use Form 5.42 for new disability claims only. Contact IMRF for the appropriate form If you need to submit medical evidence of a continuing disabling condition.)
5.45 - Employer's Notice of Termination of Disability of Trial Work Period (11/09)
5.60 - Application to serve as Representative Payee for Annuitant (07/11)
5.63 - Application to serve as Representative Payee for Annuitant by Nursing Home or Hospital (3/03)

6.01 - Request for Rollover Approval for Past Service (10/07)
6.01E - Request for Rollover Approval for the Early Retirement Incentive (ERI) (07/11)
6.02J - Application for Military Service Credit (09/07)
6.03 - Application for Reinstatement of Service Credit (02/08)
6.04 - Application for Retroactive Service Credit (12/10)
6.04A - Application for Retroactive Service Credit for... (02/08)
6.05 - Omitted Service Credit Verification (11/10)
6.06 - Conversion of Regular or SLEP Service Credit to Elected County Official (ECO) Service Credit (02/08)
6.07 - Application for Prior Service Credit (12/10)
6.09 - Conversion of Regular Service Credit to SLEP Service Credit (12/11) **
6.10 - Notice of Enrollment in IMRF
Submit a member's enrollment in IMRF via Employer Access
6.11 - Designation of Beneficiary (07/11)
6.11A - Designation of Beneficiary for Annuitants (07/11)
6.19 - Member Employment Information (7/06)
6.20 - Member Information Change
Members submit information changes via Member Access
Employers submit information changes via Employer Access
6.21 - Election to Participate for Qualifying Position (1/12) **
6.21b - Election by Elected County Official to Participate in IMRF Elected County Official Plan (8/01)
6.22 - Election of Police Chief to Participate as a SLEP Member (1/06)
6.23 - Election to Contribute Under Additional Position (6/99)
6.24 - 40-Year Service Election to Cease Contributions (5/06)
6.28 - Revocation of Election to Participate in Elected County Official Plan (1/02)
6.30 - Election to Make Voluntary Additional Contributions (07/10)
6.32 - IMRF Benefit Protection Leave (12/11) **
6.33 - Out-of-State Service Credit Authorization (06/09)
6.34 - Application by a Member of the General Assembly... (6/98)
6.38 - ECO Conversion Analysis/Estimate Request (03/2010)
6.41 - Termination of IMRF Participation
Submit a member's termination of participation via Employer Access
6.62 - Resolution - Military Leave Authorization (08/04)
6.62a - Resolution - To Allow LIMITED Service Credit for Military Leave that INTERRUPTED IMRF Participation (2/04)
63A - Resolution - Military Service Credit (8/07)
63A - Resolution - Military Service Credit, Enterable PDF form (08/07)
6.64 - Resolution - Elected Officials (01.12) **
6.68 - Resolution - Adoption of the 1,000 Hour... (08/11) **
6.71 - Certificate of Sheriff's Law Enforcement Service (09/07)
6.72 - Resolution - To Include Compensation Paid Under an IRC Section 125 Plan as IMRF Earnings (8/03)
6.73 - Resolution - To Include Compensation Paid Under a Retirement Health Savings Plan as IMRF Earnings (4/03)
6.74 - Resolution - To Include Taxable Allowances as IMRF Earnings(12/11) **
6.77 - Resolution - To Adopt Early Retirement Incentive... (01/11)
6.78 - Resolution - To Adopt Amortization Period for IMRF ERI (7/03)
6.80 - Suggested Form of Resolution To Adopt Alternative Benefit Program for County Officers (10/08)
6.82 - Suggested Form of Resolution to Revoke Alternative Benefit Program for County Officers (3/02)
6.83 - Suggested Form of Resolution to Require Additional Member Contributions for Past Service Converted to the Alternative Benefit Program for County Officers (7/00)
6.85 - Resolution - For Employer Pick Up of Member Contributions... (12/05)
6.88 - Suggested Form of Resolution to designate the regional office of education as an IMRF reporting entity distinct from the county (10/08)
6.92 - IMRF Transfer to State Employees Retirement System (SERS Alternative Retirement Formula Plan) Under Public Act 95-0530 (08/07)
6.94 - Elected County Official Stipend Purchase Under Public Act 96-0961 (HB 4644) (07/10)
6.95 - Article 3 Police Pension Fund Transfer to IMRF Under Public Act 97-0273

7.10 - Health Insurance Continuation Through Employer—Premium Deduction Authorization (05/11)
7.12D - Election For Deductions for Health or Long Term Care Insurance Premiums Paid Directly to Insurer (Rev. 1/09)
7.12E - Election For Deductions Health or Long Term Care Premiums Paid through Employer or Endorsed Plan Administrator (Rev. 01/09)