Pension Fund Refund Form

CERTIFICATION FORM

Annual Statement for Fiscal Year Ended_____________

of the___________________________________________________________________________________ ^{(Name of Fund)}

__________________________________________
^{(Date of Electronic Filling)}

__________________________________________
^{(Person Filing)}

State of Illinois

County of ____________________________

____________________________ President,

____________________________ Treasurer of the

_____________________________Secretary,

________________________________
^{(Name of Fund)}

being duly sworn, each for himself deposes and says that they are the above described officers of the said Pension Fund and that the electronically filed annual statement referred to above is a full, true and correct exhibit of all Assets, Liabilities, Income, and Disbursements, and of the conditions of the said Fund on the said _______ day of _____________, 20____, and for the fiscal year ended on that day, according to their information, knowledge and belief, respectively and that the assets, liabilities, revenues, and expenses are in agreement with the annual financial audit conducted by and independent Ceritfied Public Accountant in accordance with generally accepted auditing standards for local government.

Subscribed and sworn to before me this ______ day of __________________, 20______	__________________________ President __________________________ Secretary __________________________ Treasurer
(Notary Public) (Notary Public)	Important: When completed, filed and signed, mail to: DOI, Pension Division 320 West Washington St. Springfield, Il. 62767-001