F-12A Annual Survey of State-Administered Public-Employee Reti

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Overview

F-12A Part 1
F-12A Part 2
F-12A Part 3
F-12A Parts 4 & 5
F-12A Parts 6 & 7
F-12A Part 8
F-12A Part 9
F-12A Parts 10 & 11
F-12A Part 12
F-12A Parts 13 & 14

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Sheet 1: F-12A Part 1

F-12A (2007)

OMB No. XXXX-XXXX; Approval Expires ??/??/20??

(??/??/2007)

2006 Annual Survey of State Administered

Public-Employee Retirement Systems

U.S. DEPARTMENT OF COMMERCE

In correspondence pertaining to this report, please refer to the ID printed above your address

Economics and Statistics Administration

U.S. CENSUS BUREAU

12 3 456 789 876 54321

X1 01. 0000

RETURN TO:

SEQ123-45678

F-12

U.S. Census Bureau

1201 East 10th Street

Jeffersonville, IN 47132-0001

STATE EMPLOYEES RETIREMENT SYSTEM

If you have any questions,

PO BOX 13

please call 1-888-529-1963

SOMECITY

XX

12345-6789

weekdays, 8:00 a.m. to

5:30 p.m. EST.

Questions can also be

e-mailed to:

[email protected]

Please correct any errors in name, address, or ZIP Code.

GENERAL INSTRUCTIONS

Before filling out this form, please read carefully each part and all related definitions and instructions.

Note especially:

1.

Report separately for Defined Benefit, Defined Contribution, and Postemployment Healthcare plans.

2.

Report corporate stocks and bonds at market value, and adhere to Governmental

Accounting Standards Board (GASB) guidelines when reporting gains and losses on investments.

3.

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 system members.

4.

Do not delay reporting to await finally audited figures, if substantially accurate figures can be supplied on a

preliminary basis.

5.

Use a black or blue ball point pen.

RESPONDENT INFORMATION:

Name of person completing report - Please print

Title of person completing report - Please print

Telephone Number

Area Code

Number

Ext.

E-mail Address - Please print

Part 1

PLAN INFORMATION FOR DEFINED BENEFIT PLANS

A.

Are new employees covered under this pension plan?

Yes

No

B.

Fiscal Year Ending Date

Mark (X) in the appropriate box below to indicate the ending date of your system's fiscal year.

Please report figures for your system's fiscal year that ended between July 1, 2006 and June 30, 2007.

Report for this fiscal year even though a more recent one may be available.

2006

2007

July

October

January

April

August

November

February

May

September

December

March

June

Please continue on the next page

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Sheet 2: F-12A Part 2

Part 2

RECEIPTS/PAYMENTS FOR DEFINED BENEFIT PLANS

A.

RECEIPTS DURING FISCAL YEAR - Report receipts during the fiscal year indicated in Part 1.

Exclude amounts received from repayment of loans made to members.

1.

EMPLOYEE CONTRIBUTIONS - Total amounts contributed by all

member employees or withheld from their salaries for financing benefits.

Employee Contributions

a.

State employees - From employees of the state government,

including employees of state colleges and other state institutions

.00

and agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

X02

b.

Local employees - From employees of the counties, cities,

.00

local public schools, and other local government agencies . . . . . . . . .

X01

2.

EMPLOYER (GOVERNMENT) CONTRIBUTIONS - Total amounts

received from state and local governments for financial support of your

system, including any taxes credited directly to the system.

Government Contributions

a.

State government contributions - From state government, including

including state colleges and other state institutions and agencies.

.00

1.

State contributions to own system on behalf of state employees. .

Z99

.00

2.

State contributions to own system on behalf of local employees. .

V87

.00

3.

Total State Contributions - Sum of items 2a1 and 2a2 . . . . . . . .

X06

b.

Local government contributions - From counties, cities, local public

.00

schools, and other local government agencies . . . . . . . . . . . . . . . . .

X05

3.

EARNINGS ON INVESTMENTS - Interest, dividends, rents, and other

earnings on investments. Exclude any recorded profits or recorded

Investment Earnings and Other Receipts

losses on investment transactions and report in Section B below.

.00

a.

Rentals from the state government. . . . . . . . . . . . . . . . . . . . . . . . . .

Z98

.00

b.

Interest Earnings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Z71

.00

c.

Dividend Earnings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Z72

d.

Other Investment Earnings

.00

Please specify. . . . . . . . . . . .

Z73

.00

e.

Total Earnings on Investments - Sum of items 3a through 3d . . . . .

X08

4.

OTHER RECEIPTS - Private gifts

.00

or donations, an the like. Specify. .

Z95

Net Gains (Losses)

B.

NET GAINS/LOSSES ON INVESTMENTS IN MARKET/FAIR VALUE -

Z96

Include both realized and unrealized gains (losses). . . . . . . . . . . . . . . . . . . . .

Z91

C.

PAYMENTS DURING FISCAL YEAR - Exclude amounts paid out for

purchase of investments and for loans made to members.

Payments

1.

BENEFIT PAYMENTS - Report annual amounts.

.00

a.

Retirement Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Z13

.00

b.

Disability Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Z14

.00

c.

Survivor Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Z15

.00

d.

Other Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Z16

.00

e.

Total Benefits Paid - Sum of items 1a through 1d . . . . . . . . . . . . . .

X11

2.

WITHDRAWALS - Amounts paid to employees, former employees, or their

survivors, representing return of contributions made by employees during the

.00

period of their employment, and any interest on such amounts. . . . . . . . . .

X12

.00

3.

ADMINISTRATIVE EXPENSES - Include investment fees. . . . . . . . . . . . . .

Z93

.00

4.

OTHER PAYMENTS - Specify. . . .

. . . . . . . .

Z90

Please continue on the next page

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Sheet 3: F-12A Part 3

Part 3

HOLDINGS AND INVESTMENTS FOR DEFINED BENEFIT PLANS

Cash and Short-term Investments

A.

CASH AND SHORT-TERM INVESTMENTS

.00

1.

CASH ON HAND AND DEMAND DEPOSITS. . . . . . . . . . . . . . . . . . . . . .

Z88

.00

2.

TIME OR SAVINGS DEPOSITS - Include certificates of deposit . . . . . . . .

Z87

3.

ALL OTHER SHORT-TERM INVESTMENTS, including securities in

repurchase agreements, commercial and finance company

paper and bankers acceptances, and miscellaneous

.00

money market funds. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Z68

4.

TOTAL CASH AND SHORT-TERM INVESTMENTS -

.00

Sum of items A1 through A3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

X21

B.

FEDERAL GOVERNMENT SECURITIES

Federal Government Securities

1.

FEDERAL TREASURY SECURITIES - Obligations of U.S. Treasury

.00

(including short-term notes) and Federal Financing Bank. . . . . . . . . . . . . .

X89

2.

FEDERAL AGENCY SECURITIES - Bonds and mortgage-backed

securities (where applicable) issued by CCC, Export-Import Bank,

FHA, GNMA, Postal Service, and TVA.

.00

Report directly held mortgages in Section E below . . . . . . . . . . . . . . . . . .

X33

3.

TOTAL FEDERAL GOVERNMENT SECURITIES -

.00

Sum of items B1 and B2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

X30

C.

CORPORATE BONDS

Corporate Bonds

1.

FEDERALLY-SPONSORED AGENCIES - Bonds and

mortgage-backed securities (where applicable) issued by

.00

FHLB, FHLMC, FNMA, Farm credit banks, and SLMA . . . . . . . . . . . . . . .

Z62

2.

CORPORATE BONDS, OTHER - Include debentures, convertible

.00

bonds, and railroad equipment certificates . . . . . . . . . . . . . . . . . . . . . . . .

Z63

.00

3.

TOTAL CORPORATE BONDS - Sum of items C1 and C2. . . . . . . . . . . . .

Z77

Corporate Stocks

D.

CORPORATE STOCKS -

.00

Include common and preferred stocks, and warrants. . . . . . . . . . . . . . . . . . . . .

Z78

E.

MORTGAGES HELD DIRECTLY - Exclude mortgage-backed securities,

Mortgages Held Directly

to be reported at B2, C1, or C2; also exclude directly held real property

.00

to be reported at item G1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

X42

F.

OTHER SECURITIES

1.

INVESTMENTS HELD IN TRUST BY OTHER AGENCIES -

Other Securities

Include funds administered by private agencies, guaranteed

investment accounts, and your share of funds in

.00

governmental investment accounts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Z84

.00

2.

STATE AND LOCAL GOVERNMENT SECURITIES . . . . . . . . . . . . . . . . .

X35

3.

FOREIGN AND INTERNATIONAL SECURITIES - Include

.00

corporate equities and corporate stocks. . . . . . . . . . . . . . . . . . . . . . . . . .

Z70

4.

OTHER SECURITIES - Include shares held in mutual funds, conditional

sales contracts, direct loans,

loans to members, etc.

.00

Specify. . . . . . . . . . . . . . . .

Z83

.00

5.

TOTAL OTHER SECURITIES - Sum of items F1 through F4 . . . . . . . . . . .

X44

G.

OTHER INVESTMENTS

Other Investments

1.

REAL PROPERTY - Report only directly held property; report property held

.00

in investment trusts and in pooled or partnership agreements at G2 . . . . . .

X46

2.

OTHER INVESTMENTS - Include venture capital, partnerships,

real estate investment trusts,

and leveraged buy outs -

.00

Specify. . . . . . . . . . . . . . . .

X47

.00

3.

TOTAL OTHER INVESTMENTS - Sum of items G1 and G2. . . . . . . . . . . .

Z82

H.

TOTAL CASH AND SECURITY HOLDINGS OF PUBLIC

Holdings and Investments

EMPLOYEE RETIREMENT SYSTEM -

.00

Sum of items A through G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Z81

Please continue on the next page

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Sheet 4: F-12A Parts 4 & 5

Part 4

MEMBERSHIP AND BENEFITS FOR DEFINED BENEFIT PLANS

Please report the figures requested below, as of the last month of your fiscal year reported on page 1,

or the month nearest to that permitted by your records. If detailed figures are not available for an item,

please enter an estimate and mark it with an asterisk (*).

A.

MEMBERS OF YOUR RETIREMENT SYSTEM -

Number

Exclude beneficiaries.

of

Participants

1.

ACTIVE MEMBERS - Current contributors in contributory

systems, or employees in non-contributory plans.

a.

Employed by your state government

(including state institutions and agencies)

Z76

b.

Employed by local governments

(including local agencies)

Z75

c.

Total active members -

Sum of items 1a and 1b

Z01

2.

INACTIVE MEMBERS - Former employees and

employees on military or other extended leave without

pay having retained retirement credits, but

not currently receiving retirement benefit payments.

Z02

Number

Amount paid

B.

BENEFICIARIES RECEIVING PERIODIC BENEFIT

of

during month

PAYMENTS DURING MONTH - Please provide estimates if

Payees

Omit cents

detailed data is not available.

(a)

(b)

1.

Former active members of system, retired on

.00

account of age or service

Z03

Z08

2.

Former active members of system, retired on

.00

account of disability

Z04

Z09

.00

3.

Survivors of deceased former active members

Z05

Z10

Number

Amount paid

C.

RECIPIENTS OF LUMP-SUM PAYMENTS DURING MONTH

of

during month

REPORTED

Payees

Omit cents

(a)

(b)

1.

Withdrawals and other one-time payments

.00

(other than loans) made to present or

Z06

Z11

former members of system

2.

Lump-sum (nonrecurrent) payments made to

.00

survivors of deceased former active members

Z07

Z12

Part 5

LIABILITIES FOR DEFINED BENEFIT PLANS

A.

Please provide an actuarial estimate of your pension fund's total liabilities (present value

of current and future benefits).

.00

.00

Beginning of reference year . . . . . . . .

Z17

End of reference year . . .

Z18

B.

Please provide an actuarial estimate of accrued liabilities

.00

for plan benefits for the reference year. . . . . . . . . . . . . . . .

Z19

C.

Please check the actuarial cost method used to produce the estimates above.

Entry age or entry age normal

If other, please specify . . . . . . .

D.

Please indicate the discount rate used in present value calculations.

E.

Are future benefits indexed to inflation? Please check the appropriate selection.

Greater than CPI

CPI

Less than CPI

Please continue on the next page

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Sheet 5: F-12A Parts 6 & 7

Part 6

PLAN INFORMATION FOR DEFINED CONTRIBUTION PLANS

A.

In addition to the defined benefit plan reported here, does your system offer a defined contribution plan?

If not, skip to Part 10.

Yes

No

B.

Are new employees covered under this pension plan?

Yes

No

C.

List all defined contribution plans that your system offers below.

Report summary data combining all defined contribution plans.

Part 7

RECEIPTS/PAYMENTS FOR DEFINED CONTRIBUTION PLANS

A.

RECEIPTS DURING FISCAL YEAR - Report receipts during the fiscal year indicated in Part 1.

Exclude amounts received from repayment of loans made to members.

1.

EMPLOYEE CONTRIBUTIONS - Total amounts contributed by all

member employees or withheld from their salaries for financing benefits.

Employee Contributions

a.

State employees - From employees of the state government,

including employees of state colleges and other state institutions

.00

and agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

X02DC

b.

Local employees - From employees of the counties, cities,

.00

local public schools, and other local government agencies . . . . . . . . .

X01DC

2.

EMPLOYER (GOVERNMENT) CONTRIBUTIONS - Total amounts

received from state and local governments for financial support of your

system, including any taxes credited directly to the system.

Government Contributions

a.

State government contributions - From state government, including

including state colleges and other state institutions and agencies.

.00

1.

State contributions to own system on behalf of state employees. .

Z99DC

.00

2.

State contributions to own system on behalf of local employees. .

V87DC

.00

3.

Total State Contributions - Sum of items 2a1 and 2a2 . . . . . . . .

X06DC

b.

Local government contributions - From counties, cities, local

.00

public schools, and other local government agencies . . . . . . . . . . . . . .

X05DC

3.

EARNINGS ON INVESTMENTS - Interest, dividends, rents, and other

earnings on investments. Exclude any recorded profits or recorded

Investment Earnings and Other Receipts

losses on investment transactions and report in Section B below.

.00

a.

Rentals from the state government. . . . . . . . . . . . . . . . . . . . . . . . . .

Z98DC

.00

b.

Interest Earnings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Z71DC

.00

c.

Dividend Earnings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Z72DC

d.

Other Investment Earnings

.00

Please specify. . . . . . . . . . . .

Z73DC

.00

e.

Total Earnings on Investments - Sum of items 3a through 3d . . . . .

X08DC

4.

OTHER RECEIPTS - Private gifts

.00

or donations, an the like. Specify. .

Z95DC

Net Gains (Losses)

B.

NET GAINS/LOSSES ON INVESTMENTS IN MARKET/FAIR VALUE -

Z96DC

Include both realized and unrealized gains (losses). . . . . . . . . . . . . . . . . . . . .

Z91DC

C.

PAYMENTS DURING FISCAL YEAR - Exclude amounts paid out for

purchase of investments and for loans made to members.

1.

WITHDRAWALS - Amounts paid to employees, former employees, or

their survivors, representing return of contributions made by employees

.00

during the period of their employment, and any interest on such amounts. . .

X12DC

.00

2.

ADMINISTRATIVE EXPENSES - Include investment fees. . . . . . . . . . . . . .

Z93DC

.00

3.

OTHER PAYMENTS - Specify. . . .

Z90DC

Please continue on the next page

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Sheet 6: F-12A Part 8

Part 8

HOLDINGS AND INVESTMENTS FOR DEFINED CONTRIBUTION PLANS

Cash and Short-term Investments

A.

CASH AND SHORT-TERM INVESTMENTS

.00

1.

CASH ON HAND AND DEMAND DEPOSITS. . . . . . . . . . . . . . . . . . . . . .

Z88DC

.00

2.

TIME OR SAVINGS DEPOSITS - Include certificates of deposit . . . . . . . .

Z87DC

3.

ALL OTHER SHORT-TERM INVESTMENTS, including securities in

repurchase agreements, commercial and finance company

paper and bankers acceptances, and miscellaneous

.00

money market funds. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Z68DC

4.

TOTAL CASH AND SHORT-TERM INVESTMENTS -

.00

Sum of items A1 through A3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

X21DC

B.

FEDERAL GOVERNMENT SECURITIES

Federal Government Securities

1.

FEDERAL TREASURY SECURITIES - Obligations of U.S. Treasury

.00

(including short-term notes) and Federal Financing Bank. . . . . . . . . . . . . .

Z89DC

2.

FEDERAL AGENCY SECURITIES - Bonds and mortgage-backed

securities (where applicable) issued by CCC, Export-Import Bank,

FHA, GNMA, Postal Service, and TVA.

.00

Report directly held mortgages in Section E below . . . . . . . . . . . . . . . . . .

X33DC

3.

TOTAL FEDERAL GOVERNMENT SECURITIES -

.00

Sum of items B1 and B2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

X30DC

C.

CORPORATE BONDS

Corporate Bonds

1.

FEDERALLY-SPONSORED AGENCIES - Bonds and

mortgage-backed securities (where applicable) issued by

.00

FHLB, FHLMC, FNMA, Farm credit banks, and SLMA . . . . . . . . . . . . . . .

Z62DC

2.

CORPORATE BONDS, OTHER - Include debentures, convertible

.00

bonds, and railroad equipment certificates . . . . . . . . . . . . . . . . . . . . . . . .

Z63DC

.00

3.

TOTAL CORPORATE BONDS - Sum of items C1 and C2. . . . . . . . . . . . .

Z77DC

Corporate Stocks

D.

CORPORATE STOCKS -

.00

Include common and preferred stocks, and warrants. . . . . . . . . . . . . . . . . . . . .

Z78DC

E.

MORTGAGES HELD DIRECTLY - Exclude mortgage-backed securities,

Mortgages Held Directly

to be reported at B2, C1, or C2; also exclude directly held real property

.00

to be reported at item G1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

X42DC

F.

OTHER SECURITIES

1.

INVESTMENTS HELD IN TRUST BY OTHER AGENCIES -

Other Securities

Include funds administered by private agencies, guaranteed

investment accounts, and your share of funds in

.00

governmental investment accounts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Z84DC

.00

2.

STATE AND LOCAL GOVERNMENT SECURITIES . . . . . . . . . . . . . . . . .

X35DC

3.

FOREIGN AND INTERNATIONAL SECURITIES - Include

.00

corporate equities and corporate stocks. . . . . . . . . . . . . . . . . . . . . . . . . .

Z70DC

4.

OTHER SECURITIES - Include shares held in mutual funds, conditional

sales contracts, direct loans,

loans to members, etc.

.00

Specify. . . . . . . . . . . . . . . .

Z83DC

.00

5.

TOTAL OTHER SECURITIES - Sum of items F1 through F4 . . . . . . . . . . .

X44DC

G.

OTHER INVESTMENTS

Other Investments

1.

REAL PROPERTY - Report only directly held property; report property held

.00

in investment trusts and in pooled or partnership agreements at G2 . . . . . .

X46DC

2.

OTHER INVESTMENTS - Include venture capital, partnerships,

real estate investment trusts,

and leveraged buy outs -

.00

Specify. . . . . . . . . . . . . . . .

X47DC

.00

3.

TOTAL OTHER INVESTMENTS - Sum of items G1 and G2. . . . . . . . . . . .

Z82DC

H.

TOTAL CASH AND SECURITY HOLDINGS OF PUBLIC

Holdings and Investments

EMPLOYEE RETIREMENT SYSTEM -

.00

Sum of items A through G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

X81DC

Please continue on the next page

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Sheet 7: F-12A Part 9

Part 9

MEMBERSHIP AND BENEFITS FOR DEFINED CONTRIBUTION PLANS

Please report the figures requested below, as of the last month of your fiscal year reported on page 1,

or the month nearest to that permitted by your records. If detailed figures are not available for an item,

please enter an estimate and mark it with an asterisk (*).

MEMBERS OF YOUR RETIREMENT SYSTEM -

Number of

Exclude beneficiaries.

Participants

1.

ACTIVE MEMBERS - Current contributors in contributory

systems, or employees in non-contributory plans.

Z01DC

2.

INACTIVE MEMBERS - Former employees and

employees on military or other extended leave without

pay having retained retirement credits, but

not currently receiving retirement benefit payments.

Z02DC

Please continue on the next page

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Sheet 8: F-12A Parts 10 & 11

Part 10

PLAN INFORMATION FOR POSTEMPLOYMENT HEALTHCARE PLANS

A.

In addition to the defined benefit and/or defined contribution plans reported here, does your system offer a

postemployment healthcare plan? If not, skip to Part 14.

Yes

No

B.

Are new employees covered under this pension plan?

Yes

No

C.

List all postemployment healthcare plans that your system offers below.

Report summary data combining all postemployment healthcare plans.

Part 11

RECEIPTS/PAYMENTS FOR POSTEMPLOYMENT HEALTHCARE PLANS

A.

RECEIPTS DURING FISCAL YEAR - Report receipts during the fiscal year indicated in Part 1.

Exclude amounts received from repayment of loans made to members.

1.

EMPLOYEE CONTRIBUTIONS - Total amounts contributed by all

member employees or withheld from their salaries for financing benefits.

Employee Contributions

a.

State employees - From employees of the state government,

including employees of state colleges and other state institutions

.00

and agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

X02HC

b.

Local employees - From employees of the counties, cities,

.00

local public schools, and other local government agencies . . . . . . . . .

X01HC

2.

EMPLOYER (GOVERNMENT) CONTRIBUTIONS - Total amounts

received from state and local governments for financial support of your

system, including any taxes credited directly to the system.

Government Contributions

a.

State government contributions - From state government, including

including state colleges and other state institutions and agencies.

.00

1.

State contributions to own system on behalf of state employees. .

Z99HC

.00

2.

State contributions to own system on behalf of local employees. .

V87HC

.00

3.

Total State Contributions - Sum of items 2a1 and 2a2 . . . . . . . .

X06HC

b.

Local government contributions - From counties, cities, local public

.00

schools, and other local government agencies . . . . . . . . . . . . . . . . .

X05HC

3.

EARNINGS ON INVESTMENTS - Interest, dividends, rents, and other

earnings on investments. Exclude any recorded profits or recorded

Investment Earnings and Other Receipts

losses on investment transactions and report in Section B below.

.00

a.

Rentals from the state government. . . . . . . . . . . . . . . . . . . . . . . . . .

Z98HC

.00

b.

Interest Earnings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Z71HC

.00

c.

Dividend Earnings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Z72HC

d.

Other Investment Earnings

.00

Please specify. . . . . . . . . . . .

Z73HC

.00

e.

Total Earnings on Investments - Sum of items 3a through 3d . . . . .

X08HC

4.

OTHER RECEIPTS - Private gifts

.00

or donations, an the like. Specify. .

Z95HC

Net Gains (Losses)

B.

NET GAINS/LOSSES ON INVESTMENTS IN MARKET/FAIR VALUE -

Z96HC

Include both realized and unrealized gains (losses). . . . . . . . . . . . . . . . . . . . .

Z91HC

C.

PAYMENTS DURING FISCAL YEAR - Exclude amounts paid out for

purchase of investments and for loans made to members.

.00

1.

HEALTHCARE PREMIUMS TO INSURANCE CARRIERS

Z94HC

.00

2.

CLAIMS PAID

Z95HC

.00

3.

ADMINISTRATIVE EXPENSES - Include investment fees. . . . . . . . . . . . . .

Z93HC

.00

4.

OTHER PAYMENTS - Specify. . . .

Z90HC

Please continue on the next page

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Sheet 9: F-12A Part 12

Part 12

HOLDINGS AND INVESTMENTS FOR POSTEMPLOYMENT HEALTHCARE PLANS

Cash and Short-term Investments

A.

CASH AND SHORT-TERM INVESTMENTS

.00

1.

CASH ON HAND AND DEMAND DEPOSITS. . . . . . . . . . . . . . . . . . . . . .

Z88HC

.00

2.

TIME OR SAVINGS DEPOSITS - Include certificates of deposit . . . . . . . .

Z87HC

3.

ALL OTHER SHORT-TERM INVESTMENTS, including securities in

repurchase agreements, commercial and finance company

paper and bankers acceptances, and miscellaneous

.00

money market funds. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Z68HC

4.

TOTAL CASH AND SHORT-TERM INVESTMENTS -

.00

Sum of items A1 through A3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

X21HC

B.

FEDERAL GOVERNMENT SECURITIES

Federal Government Securities

1.

FEDERAL TREASURY SECURITIES - Obligations of U.S. Treasury

.00

(including short-term notes) and Federal Financing Bank. . . . . . . . . . . . . .

Z89HC

2.

FEDERAL AGENCY SECURITIES - Bonds and mortgage-backed

securities (where applicable) issued by CCC, Export-Import Bank,

FHA, GNMA, Postal Service, and TVA.

.00

Report directly held mortgages in Section E below . . . . . . . . . . . . . . . . . .

X33HC

3.

TOTAL FEDERAL GOVERNMENT SECURITIES -

.00

Sum of items B1 and B2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

X30HC

C.

CORPORATE BONDS

Corporate Bonds

1.

FEDERALLY-SPONSORED AGENCIES - Bonds and

mortgage-backed securities (where applicable) issued by

.00

FHLB, FHLMC, FNMA, Farm credit banks, and SLMA . . . . . . . . . . . . . . .

Z62HC

2.

CORPORATE BONDS, OTHER - Include debentures, convertible

.00

bonds, and railroad equipment certificates . . . . . . . . . . . . . . . . . . . . . . . .

Z63HC

.00

3.

TOTAL CORPORATE BONDS - Sum of items C1 and C2. . . . . . . . . . . . .

Z77HC

Corporate Stocks

D.

CORPORATE STOCKS -

.00

Include common and preferred stocks, and warrants. . . . . . . . . . . . . . . . . . . . .

Z78HC

E.

MORTGAGES HELD DIRECTLY - Exclude mortgage-backed securities,

Mortgages Held Directly

to be reported at B2, C1, or C2; also exclude directly held real property

.00

to be reported at item G1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

X42HC

F.

OTHER SECURITIES

1.

INVESTMENTS HELD IN TRUST BY OTHER AGENCIES -

Other Securities

Include funds administered by private agencies, guaranteed

investment accounts, and your share of funds in

.00

governmental investment accounts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Z84HC

.00

2.

STATE AND LOCAL GOVERNMENT SECURITIES . . . . . . . . . . . . . . . . .

X35HC

3.

FOREIGN AND INTERNATIONAL SECURITIES - Include

.00

corporate equities and corporate stocks. . . . . . . . . . . . . . . . . . . . . . . . . .

Z70HC

4.

OTHER SECURITIES - Include shares held in mutual funds, conditional

sales contracts, direct loans,

loans to members, etc.

.00

Specify. . . . . . . . . . . . . . . .

Z83HC

.00

5.

TOTAL OTHER SECURITIES - Sum of items F1 through F4 . . . . . . . . . . .

X44HC

G.

OTHER INVESTMENTS

Other Investments

1.

REAL PROPERTY - Report only directly held property; report property held

.00

in investment trusts and in pooled or partnership agreements at G2 . . . . . .

X46HC

2.

OTHER INVESTMENTS - Include venture capital, partnerships,

real estate investment trusts,

and leveraged buy outs -

.00

Specify. . . . . . . . . . . . . . . .

X47HC

.00

3.

TOTAL OTHER INVESTMENTS - Sum of items G1 and G2. . . . . . . . . . . .

Z82HC

H.

TOTAL CASH AND SECURITY HOLDINGS OF PUBLIC

Holdings and Investments

EMPLOYEE RETIREMENT SYSTEM -

.00

Sum of items A through G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Z81HC

Please continue on the next page

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Sheet 10: F-12A Parts 13 & 14

Part 13

MEMBERSHIP AND BENEFITS FOR POSTEMPLOYMENT HEALTHCARE PLANS

Please report the figures requested below, as of the last month of your fiscal year reported on page 1,

or the month nearest to that permitted by your records. If detailed figures are not available for an item,

please enter an estimate and mark it with an asterisk (*).

MEMBERS OF YOUR RETIREMENT SYSTEM -

Number of

Exclude beneficiaries.

Participants

1.

ACTIVE MEMBERS - Current contributors in contributory

systems, or employees in non-contributory plans.

a.

Members who are at least 65 years of age.

Z20HC

b.

Members who are under the age of 65.

Z21HC

c.

Total active members -

Z01HC

Sum of items 1a and 1b

2.

INACTIVE MEMBERS - Former employees and

employees on military or other extended leave without

pay having retained retirement credits, but

not currently receiving retirement benefit payments.

a.

Inactive members who are at least 65 years of age.

Z22HC

b.

Inactive members who are under the age of 65.

Z23HC

c.

Total inactive members -

Z02HC

Sum of items 1a and 1b

Part 14

REMARKS

Thank you for your report. Please return to:

U.S. Census Bureau

1201 East 10th Street

Jeffersonville, IN 47132-0001

This form has been approved by the Office of Management and Budget (OMB) and has been given the number XXXX-XXXX. 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 size of their service areas, the amount of population

served, and the extent and complexity of their financial accounts. We estimate public reporting burden for this collection of information to vary

from 1.5 to 8.0 hours per response, with an average of 4.0 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 [email protected]; use "Paperwork Project XXXX-XXXX" as the subject.

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