Form F-13 ANNUAL SURVEY OF STATE GOVERNMENT FINANCES Finances of I

Attachment 2
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

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

FORM

F-13

2019 ANNUAL
SURVEY OF STATE GOVERNMENT FINANCES
Finances of Insurance Trust Systems

(09-05-2019)

OMB No. 0607-0585: Approval Expires 06/30/2020

DUE DATE:

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

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questions?
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In correspondence
pertaining to this report,
please refer to the first
9 digits in the 1st line of
the address box.
NOTE: Title 13 United States Code (U.S.C.), Sections 161 and 182 authorizes the Census Bureau to conduct this collection and to request your voluntary assistance. These data are
subject to provisions of Title 13, U.S.C., Section 9(b) exempting data that are customarily provided in public records from rules of confidentiality. Per the Federal Cybersecurity
Enhancement Act of 2015, your data are protected from cybersecurity risks through screening of the systems that transmit your data.
This collection has been approved by the Office of Management and Budget (OMB). The eight-digit OMB approval number is 0607-0585 and appears at the upper right of this form.
Without this approval, we could not conduct this survey.
Please note that this collection of information 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. We estimate the time to complete this survey varies from 30 minutes to 2 hours, with an average of 1 hour, including the 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: EWD Survey Comments 0607-0585, U.S.Census Bureau,
4600 Silver Hill Road, Room EWD-5K071, Washington, DC 20233. You may e-mail comments to [email protected]. Be sure to use EWD Survey Comments 0607-0585 as
the subject.

GENERAL INSTRUCTIONS
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, 2018 and September 30, 2019.
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.

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:

17139015

§2.{0¤

1

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, 2018 and September 30, 2019? Use this fiscal year even though a more recent
one may be available. Mark "X" only one box.
2018

2019

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

17139023

§2.{8¤

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
securities issued by CCC, Export-Import Bank, FHA, GNMA,
Postal Service, and TVA . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D. Securities of State and local governments and their
agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

§2.{@¤

E.

Other securities
1. Corporate bonds

2.

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

3.

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

4.

17139031

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?

§2.{R¤

Name of contact person - Please print

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.

Form F-13

17139049

7