F-13 Survey of the Finances of Insurance Trust Systems

F-13 (2010)
F-13

FORM
(5-10-2010)

OMB No. 0607-0585: Approval Expires 06/30/2011
In correspondence pertaining to this report, please refer to the
ID printed above your address.

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

2010 Annual
Survey of the Finances
of Insurance Trust
Systems

Data supplied by
Name
Title

Area code

Telephone
Number

RETURN TO

▼
U.S. Census Bureau
1201 East 10th Street
Jeffersonville, IN 47132-0001
System’s fiscal year ended
Month
Day
Year

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

FROM THE DIRECTOR
U.S. CENSUS BUREAU
We are writing to request information needed for our Annual Survey of the Finances of Insurance Trust
Systems.
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 voluntary survey. If this
number were not displayed, we could not request your participation in this survey.
We estimate that it will take from 30 minutes to 2 hours to complete this form, with an average of 1 hour 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, 4600 Silver Hill Road, AMSD-3K138,
Washington, D.C. 20233. You may e-mail comments to ; use "Paperwork Project
0607-0585" as the subject.
If you have any questions concerning this request, please call the Governments Division on our toll-free
number, 1–888–590–2748.
Thank you for cooperating in this important survey.
Sincerely,

Robert M. Groves

USCENSUSBUREAU

PLEASE RETAIN A COPY OF THE COMPLETED QUESTIONNAIRE FOR YOUR FILES

CHANGES TO FORM F-13 SINCE FISCAL YEAR 2009
Definitions have changed for the following items, please see item for new definition;
Section A, Part 3: RECEIPTS DURING FISCAL YEAR – Earnings on investments
Section B, Part 2: PAYMENTS DURING FISCAL YEAR – Other payments

GENERAL INSTRUCTIONS
Before filling out this form, please read carefully each part and all related definitions and instructions. Note especially:
1. Please report figures for your system’s fiscal year which ended
between July 1, 2009 and June 30, 2010, 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 system members.

3. 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.
4. Do not delay reporting to await finally audited figures, if
substantially accurate figures can be supplied on a
preliminary basis.
5. If you have any questions, call 1– 888–590–2748.

Amount — Omit cents

Item
A. RECEIPTS DURING FISCAL YEAR
1. Contributions other than from State government — Premiums, assessments, or contributions collected
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.

$

2. Contributions from State government — Premiums or contributions paid by the State government and
State institutions or agencies for financing benefits, and any State government contributions or
appropriations for administration or other support of the system.

.00

.00

3. Earnings on investments — Interest earnings on investment securities, deposits, and other
interest-bearing accounts, including accrued interest on investment securities sold; dividends; recorded profits
on investment transactions (minus any realized losses); rentals; and other earnings on investments.

Amount — Omit cents
If total amount includes rentals from the State government — Show amount of such
receipts here. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$

.00

.00

4. Other receipts — Specify below. Exclude receipts from sale of investments.

$

a.

.00

b.

.00

c.

.00

B. PAYMENTS DURING FISCAL YEAR
1. Benefits — Amounts paid to, or on behalf of, insurance beneficiaries

$

.00

$

.00

2. Other Payments — Administrative expenses, recorded costs on investment transactions, and other costs or
payments not representing benefits. – Specify below. Exclude purchase of investments.

a.

.00

b.

.00

c.
FORM F-13 (5-10-2010)

Please review this form before transmitting original to the U.S. Census Bureau

C. CASH AND SECURITY HOLDINGS (MARKET VALUE) AT END OF
FISCAL YEAR
1. Cash and deposits — Cash on hand and demand, and time or savings deposits

$

.00

2. Federal Securities — Obligations of U.S. Treasury (including short-term notes) and Federal Financing Bank

.00

3. Other Federal Securities — CCC, Export-Import Bank, FHA, GNMA, Postal Service, and TVA

.00

4. Securities of State and local governments and their agencies

.00

5. Other securities — Bonds, stocks, mortgages, notes, loans, etc., not included in the foregoing classes. Report
amounts separately, as follows:
a. Corporate bonds (including debentures)

.00

b. Corporate stocks

.00

c. Mortgages

.00

d. Other – Exclude real property

.00

6.

Total cash and security holdings — Sum of items C1 through C5d

REMARKS

FORM F-13 (5-10-2010)

Please review this form before transmitting original to the U.S. Census Bureau