APPLICATION FOR REFUND OF PENSION
CHAMPAIGN POLICE PENSION FUND

Applicants Name ____________________________ Phone Number __________________________

I am a member of the Champaign Police Department assigned to a duty as a ______________

I received my probationary appointment on ______________, regular on _______________

I am ________ years of age and have performed Police duty as a member of the Champaign Police Department for the period of _______ years, _______ months and _______ days.

My last work day will be ____________20___

PLEASE MARK ONE OF THE FOLLOWING OPTIONS:

[ ] Please send my refund check to me at the following address:

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I understand that 21% of my refund will be deducted for Federal taxes and 10 % for early withdrawl.

[ ] Please send my refund check to the following Fund:

__________________________________________

__________________________________________

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I understand that if I am "rolling over" my refund that the check must go directly to the new Fund. I will make sure the necessary paperwork is done for this transaction.
I wish the total deductions made form my salary during my employment to be returned as provided in Section 3-124. I am also aware of and waive forever any claim to a pension under Section 3-111 unless I return to service in the future and meet requirements at that time.
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Signature of Petitioner
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Address
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Date 		________________________________
Print Name
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City, State & Zip Code
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Phone Number