Form F-10 Quarterly Survey of Public Pensions

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU
(8-4-2010)

FORM

F-10

QUARTERLY
SURVEY OF PUBLIC PENSIONS
Report for Quarter Ending:

(11-15-2011) Draft 2

OMB No. 0607-0143: Approval Expires 12/31/2014

DUE DATE:

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

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GENERAL INSTRUCTIONS
Before filling out this form, please read carefully each part and all related definitions and instructions.
Note especially:
Report figures for the last date of the calendar quarter named in the form title.
1.
2.
Report corporate stocks and bonds at market value, and adhere to Governmental Accounting Standards Boards
(GASB) guidelines when reporting gains and losses on investments. In order to obtain needed detail information,
this form has been revised to request market value for corporate bonds, corporate stocks, and foreign and
international securities.
3.
Report assets relating to all accounts and reserves of your system, INCLUDING amounts for retirement, disability,
survivors’, and other benefits.
PLEASE COMPLETE ALL ITEMS ON THE FORM. If some items do not apply to your system, write "not applicable".
4.
If some items may apply but there is a zero dollar amount, then do not leave blank. Enter zero "0".
5.
Do not delay reporting to await final figures, if substantially accurate figures can be supplied on a preliminary basis.
6.
Use a black or blue ball point pen. Do not use pencil or felt-tip pen.
Is your addressee title/department and mailing address the same as shown in the address label?
Yes – Go to 2

No – Enter correct information below

Addressee Title or Department

17102013

§2+5.¤

1

Street 1

Street 2

City

State

Zip Code

–
Please continue on the next page

Page 2
PART 1 – RECEIPTS

HOW TO
REPORT
DOLLAR
FIGURES

2

CORRECT marking example –
Please print all information clearly in
ordinary characters. (Use care to keep
characters in their respective boxes.)
$Mil.

Thou.

Dol.

1 2 3

4 5 6

7 8 0

INCORRECT marking example –
Do not put slashes through "0" or "7".
$Mil.

Thou.

Dol.

7

What were the amount of receipts during the quarter ending
Exclude
• Amounts received from sales of investments
• Amounts received from repayment of loans made to
members
A. Employee Contribution – Amounts contributed
by members or withheld from their salaries for
financing of benefits. . . . . . . . . . . . . . . . . . . . . . . .

8 9 0

?

Contributions
$Bil.

Mil.

$Bil.

Mil.

Thou.

Dol.

X01/X02

B. Government contribution – Amounts contributed
by administrating state and local governments for
financial support of your system, including any
taxes credited directly to your system . . . . . . . . . . X03/X04

X05

D. Earnings on investments – Interest, dividends,
rents and other earnings on investments. Report
recorded profits or recorded losses on
investments in item 3.

§2+56¤

E.

Form F-10

Earnings

1. Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Z71

2. Dividends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Z72

Gains and losses on investments in market/fair value
Include
• Both realized and unrealized gains(losses)

Thou.

Dol.

Gains and Losses
$Bil.

1. Realized gains – book value . . . . . . . . . . . . . . . . . .

xxx

2. Realized losses - book value . . . . . . . . . . . . . . . . . .

xxx

3. Realized gains and losses (items 1 + 2) . . . . . . . . . .

xxx

4. Unrealized gains or losses on investments –
market value, net value . . . . . . . . . . . . . . . . . . . . . .

xxx

Mil.

Thou.

Dol.

17102021

C. Other government contribution – Any
contributions from another government, not
previously reported in A or B.
Include
• State aid
• Shared taxes
• Any other amounts received from governments
on behalf of their employees . . . . . . . . . . . . . . . . . .

Please continue on the next page

Page 3
PART 2 – PAYMENTS
3

What were the payments made during the quarter ending
Exclude
• Amounts paid out for purchase of investments
• Loans made to members

?
Payments
$Bil.

A. Benefits paid – Retirement disability, survivors’,
and other benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . .

X11

B. Withdrawals – Amounts paid to members or former
members or their survivors, representing return of
contributions made by members during the period
of their employment . . . . . . . . . . . . . . . . . . . . . . . . . .

X12

Mil.

Thou.

Dol.

C. Administration
Include
• Investment fees. . . . . . . . . . . . . . . . . . . . . . . . . . . .

Z93

PART 3 – CASH AND INVESTMENTS HELD AT END OF QUARTER
4

What was the total amount of cash and investments (at market value) held at the end of the quarter
ending

?

A. Cash and Short-Term Investments
Include:
• cash on hand
• demand deposits
• time or savings deposits
• securities in repurchase agreements
• commercial and finance company
paper and bankers acceptances
• miscellaneous money market funds . . . . . . . . . . . . .

Cash and Investments
$Bil.

Mil.

Thou.

Dol.

X21

C. Corporate Bonds – Corporate bonds including
debentures, convertible bonds, and railroad
equipment certificates plus Federally sponsored
agency securities including bonds and mortgage
backed securities (where applicable) issued by SLMA .

Z77

D. Corporate Stocks
Include:
• Common and preferred stocks
• Warrants
• Private equity
• Venture capital
• Leverage buy-outs
• Investments in REITs. . . . . . . . . . . . . . . . . . . . . . . . .

Z78

E.

Foreign and International Securities
Include:
• Corporate equities
• Corporate stocks . . . . . . . . . . . . . . . . . . . . . . . . . . . . Z70

F.

Mortgages
Exclude:
• Mortgage-backed securities (report at B or C)
• Real property that is owned (report at H). . . . . . . . . .

17102039

§2+5H¤

B. Federal Government Securities – Obligations of the
U.S. Treasury (including short-term notes) and Federal
Financing Bank, bonds and mortgage-backed
securities (where applicable) issued by CCC,
Export-Import Bank, FHA, GNMA, Postal Service, and
TVA; and bonds and mortgage-backed securites
(where applicable) issued by FHLC, FHLMC, FNMA,
and Farm credit banks . . . . . . . . . . . . . . . . . . . . . . . . . X30

X42

G. Other Securities
1. Securities of state and local governments . . . . . . .
Form F-10

X35

Please continue on the next page

Page 4
PART 3 – CASH AND INVESTMENTS HELD AT END OF QUARTER – Continued
2. Other
Include:
• Funds held in trust by other agencies
• Shares held in mutual funds
• Conditional sales contracts, direct loans, and
loans to members – Specify

Z83/Z84

H. Other Investments
Include:
• Directly held property
• Partnerships
• State and local government securities
• Shares held in conditional sales contracts
• Direct loans
• Foreign currency
• Derivatives
• Guaranteed investment contracts
• Annuities
• Life insurance
• Loans to members . . . . . . . . . . . . . . . . . . . . . . . . . .

Z82

I. Total Holdings and Investments
(at market value)
(Sum of items A through H). . . . . . . . . . . . . . . . . . . . .

Z81

PART 4 – REMARKS
5

Use this space to:
a)

Explain any items that were difficult to classify;

b)

Provide additional information concerning any of the entities on the form.

PART 5 – CONTACT INFORMATION
Who should be contacted to answer questions about data reported on this form?

§2+5P¤

Area code and phone number

–

–

E-mail Address - Please print

Title of contact person - Please print

Extension

Area code and fax number

–

–

Date form was completed

Thank you for completing this form.
Retain a copy of the completed questionnaire for your records.
NOTE: The U.S. Census Bureau receives its authorization to conduct this survey from Title 13, United States Code, Section 161. This form has been approved by the Office of
Management and Budget (OMB) and given the number 0607-0143. Please note the number displayed 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 was not displayed, under the Paperwork Reduction Act, we could not request your participation in this
voluntary survey. Information provided on this questionnaire compiled from or customarily provided in public records are exempt from confidential treatment as cited in Title 13,
United States Code, Section 9.
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 population served, and the extent and
complexity of their activities. Public reporting burden for this collection of information is estimated to vary from 30 minutes to 2 hours per response, with an average of 45 minutes
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 0607-0143, U.S. Census Bureau, 4600 Silver Hill Road, AMSD-3K138, Washington, DC 20233. You may e-mail comments to [email protected]; use Paperwork Project
0607-0143 as the subject.

Form F-10

17102047

6

Name of contact person - Please print