F-13 Survey of the Finances of Insurance Trust Systems

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

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

FORM

F-13

2014 ANNUAL
SURVEY OF STATE GOVERNMENT FINANCES
Finances of Insurance Trust Systems

(03-18-2014)

OMB No. 0607-0585: Approval Expires 07/31/2017

DUE DATE:

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

Need help or have
questions?
• Visit
census.gov/govs/state/
• Call
1-866-820-7210 weekdays,
7AM to 5PM ET
• Email
govs.state.finance@
census.gov
In correspondence
pertaining to this report,
please refer to the first
9 digits in the 1st line of
the address box.

GENERAL INSTRUCTIONS

2.

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

3.

Report in whole dollars.

4.

PLEASE COMPLETE ALL ITEMS ON THE FORM. If some items do not apply to the system, do not leave
them blank. Mark these items with “None” or a dash in the reporting space provided.

5.

Do not delay reporting to await finally audited 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 a felt-tip pen.

1

Is the 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

ATTN:

17134016

§2.I1¤

Before filling out this form, please read carefully each part and all related definitions and instructions.
Note especially:
1.
Report figures for the system’s fiscal year which ended between October 1, 2013 and September 30, 2014.

Street 1

Street 2

City

State

Zip Code

Please continue on the next page

Page 2
PART 1 – ENDING DATE OF FISCAL YEAR
2

Which one of the following indicates the ending date of the system’s fiscal year that ended
between October 1, 2013 and September 30, 2014? Use this fiscal year even though a more recent
one may be available. Mark "X" only one box.
2013

2014

October

January

April

July

November

February

May

August

December

March

June

September

PART 2 – RECEIPTS
3

What was the amount of receipts during the fiscal year indicated in 2 ?
A. 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
• Amounts received from State government employees
• Dividends or return of excess premiums (report as a
deduction from total contributions)
Exclude
• Amounts received from State government (should be
reported in item B.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$Bil.

Contributions
Mil.
Thou.

Dol.

$Bil.

Mil.

Earnings
Thou.

Dol.

$Bil.

Other Receipts
Mil.
Thou.

Dol.

B. 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 . . . . . . . . . . .
C. Earnings on investments – Interest earnings on investment
securities, deposits, and other interest-bearing accounts.
Include
• Accrued interest on investment securities sold
• Recorded profits on investment transactions (minus
any realized losses)
• Rentals
• Other earnings on investments

D. Other receipts

Form F-13

Exclude
• Receipts from sale of investments
Specify and report other receipts:
1.

...

2.

...

3.

...

Please continue on the next page

17134024

§2.I9¤

Exclude
• Rentals from the State government . . . . . . . . . . . . . . . .

Page 3
PART 3 – PAYMENTS
4

What was the amount of payments made during the fiscal year indicated in 2 ?
$Bil.

Mil.

Payments
Thou.

Dol.

A. Benefits – Amounts paid to, or on behalf of, insurance
beneficiaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
B. Other payments
Include
• Administrative expenses
• Recorded costs on investment transactions
• Other costs or payments not representing benefits
Exclude
• Purchase of investments
Specify and report other payments:
1.

...

2.

...

3.

...

PART 4 – CASH AND INVESTMENTS HELD AT THE END OF FISCAL YEAR
5

What was the total amount of cash and investments (at market value) held by the system at the end
of the fiscal year indicated in 2 ?
Amount at End of Fiscal Year
$Bil.
Mil.
Thou.
Dol.
A. Cash and deposits – Cash on hand and demand, and
time or savings deposits . . . . . . . . . . . . . . . . . . . . . . . . . . .
B. Federal government securities – Obligations of the US
Treasury and Federal Financing Bank.
Include
• Short term notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
C. Federal agency securities – Bonds and mortgage-backed
securites issued by CCC, Export-Import Bank, FHA, GNMA,
Postal Service, and TVA . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D. Securities of State and local governments and their
agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

§2.IA¤

E.

Other securities
1. Corporate bonds

2.

Corporate stocks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3.

Mortgages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4.

17134032

Include
• Debentures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other
Exclude
• Real property . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

F.
Form F-13

TOTAL – (Sum of items A. through E.) . . . . . . . . . . . . . . . . .
Please continue on the next page

Page 4
PART 5 – REMARKS
6

Use this space for any explanations that may be essential in understanding the reported data.
Include
• Any significant changes occurring within the last year
• Any difficulties encountered in completing this form

PART 6 – CONTACT INFORMATION
Who should be contacted to answer questions about data reported on this form?

Name of contact person - Please print

§2.II¤

Area code and phone number

Email Address - Please print

Title of contact person - Please print

Extension

Area code and fax number

Date form was completed
(MM)
(DD)
(YYYY)

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 182. This form has been approved by the Office of
Management and Budget (OMB) and given the number 0607-0585. 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 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, DC 20233. You may e-mail comments to [email protected]; use Paperwork Project
0607-0585 as the subject.

Form F-13

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