F-13 Annual Survey of the Finances of Insurance Trust Systems

F-13

1.2004)

~~o.

In correspondence
pertaining to this report,
Census File Number above your address.

FORM r-13
(8-4-2004)

u.s.

0607-0585:

Approval Expires 03/31/2005

please refer to the

DEPARTMENT
OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU

2004
SURVEY

OF THE

FINANCES

OF

INSURANCE

TRUST

SYSTEMS
Data supplied

by

I Name

Title

I Area

code

Telephone
I Number

RETURN

TO

U.S. Census Bureau
1201 East 10th Street
Jeffersonville,
IN 47132-0001

(Please correct any error in name, address, and ZIP Code)

System's fiscal year ended
! Month

I Day

Name

of

systerr,

I Year

This form has been approved by the Office of Management and Budget (OMB) and has been given the number 0607-0585. Please
note that we have displayed this number in the upper right hand corner of this form. Display of this number confirms that we have
approval from OMB to conduct this survey. If this number were not displayed, we could not request your participation in this survey
Please note that this is a national form that applies to governments with wide differences in the size of their service areas, the amount of the
population served, and the extent and complexity of their financial accounts. We estimate public reporting burden for this collection of
information to vary from .5 to 2.0 hours per response, with an average of 1.0 hours per response, including time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to: Paperwork Project 0607-0585, U.S. Census Bureau, 4700 Silver Hill Road, Stop 1500, Washington, D.C. 20233-1500. You may
e-mail comments to Paperwork@census.gov;
use "Paperwork Project 0607-0585" as the subject.

Before

filling

out this

form,

GENERAL
INSTRUCTIONS
please read carefully each part and all related definitions and instructions.

1.

Please report figures for your system's fiscal year which ended
between July 1, 2003 and June 30, 2004, and indicate the
closing date of the reported fiscal year in the space provided above.

2.

Report figures relating to all accounts and reserves of your.
system, including amounts for retirement, disability, survivors,
and other benefits, as well as any amounts for administration
of the system. Report in whole dollars.
Exclude
transfers
between reserves of the system, and also any investment
transactions relating to loans to syste~embers.

3.

4.

__~~f

Note

...,
,
Do not ~elay reporting. to await finally audl,ted figures, If
sub.st~ntlally ac~urate figures can be supplied on a
preliminary basis.
~ou hayeany

questions, call 1- 888-590-2748.

Item
A.

RECEIPTS
1.

2.

3.

DURING

FISCAL

Amount

Omit cents

YEAR

Contributions
other than from State government
-Premiums,
assessments, or contributions
from employers (other than the State government) and from employees for financing benefits. Include
amounts received from local governments and their employees, and from State government employees.
Exclude
here and report in item A2 any State government contributions.

collected

$

Contributions
from State government
-Premiums
or contributions paid by the State government
State institutions or agencies for financing benefits, and any State government contributions or
appropriations for administration or other support of the system.
-Earnings
on investments
-Interest,
dividends, rents, and other earnings on investments, and any
recorded profits on investment transactions (e.g., premiums on investments, and the like, if recorded as
receipts of the system.)

Amount
If total amount includes rentals from the State government
receipts here.

SCENSUSBUREAU

especially:

Please complete
all parts of the form. If some items do
not apply to your system, do not merely leave them blank,
but enter "None" or a dash in the reporting space provided.

PLEASE

,00

and

,00

Omit cents I

Show amount of such

$
RETAIN

A COPYOF

THE COMPLETED

.00
QUESTIONNAIRE

00
FOR YOUR FILES

Item

Amount -Omit

cents

A. RECEIPTS DURING FISCAL YEAR -Continued
4. Other receipts -Specify below. Exclude receipts from sale of investments.

a.

$

b.

00

c.
B.

00

PAYMENTS

DURING

1.

Benefits

2.

Other
Payments
costs or payments

FISCAL

-Amounts

YEAR

paid to, or on behalf of, insurance beneficiaries

-Administrative
not representing

$

expenses,
recorded
costs or losses
benefits.
-Specify
below. Exclude

on investment
transactions,
purchase
of investments.

.00

and other

a.

$

b.

1.00

00

c.
C.

ooi

.00

CASH AND SECURITY
FISCAL YEAR
1.

Cash

2.

Federal

3.

Other

HOLDINGS

and depo!!!~-

Securities

Federal

BOOK

VALUE

AT END OF

Cash on hand a~emand,

-Obligations

Securities

and time or savings deposits

of U.S. T~ry

-CCC,

(including sho~

Export-lmport

$

notes) and Federal Financing Bank

00

00

Bank, FHA, GNMA, Postal Service, and TVA
.00,

4.
5.

Securities
of State and local governments
~
Other securities
-Bonds,
stocks, mortgages,
amounts separately, as follows:

and their

agencies

00

notes, loans, etc., not included in the foregoing classes. Report

a. Corporate bonds (including debentures)
-~

00

.00

001

d.

-~

Other

6.

-Exclude

real

property.

1.00

T~tal

cash

and s!curity

holdings

-~um

of items C1 thro~h

C5d
,001

REMARKS

FORM F-13 (8-4-2004)

Please review this form before transmitting ori~,inal to the U.S. Census Bureau