Employee __________________________________________________
Social Security number (last four digits) ___ ___ ___ ___
Employer name _____________________________________________
Employer number __________________
DEPOSIT AND SERVICE REPORT
To enable us to compute and pay the benefit to the employee listed above, complete and return this report at the earliest date
possible after you can accurately determine the total earnings and deposits for the fiscal year. The certification should
be executed even though final salary may be paid at a later date. Early completion will speed both the processing of the
application and the issuance of the first monthly benefit payment.
For the STRS Ohio fiscal year beginning July 1, 2014, and ending June 30, 2015.
EARNINGS
1. Earnings under employee’s 2014–2015 base contract ............................................................. $___________________
2. Balance of employee’s 2013–2014 contract earned in the 2014–2015 fiscal year .................. $___________________
3. Amount reported in the 2014–2015 fiscal year but earned in the 2013–2014 fiscal year
(prior to July 1, 2014) .............................................................................................................. $___________________
4. Supplemental or additional earnings (please itemize). If more space is needed, attach an additional sheet with this form.
Description
Amount
________________________________________________ $ _________________
Total:
________________________________________________ $ _________________
Total:
________________________________________________ $ _________________ Total: $___________________
5. Pickup included in compensation for retirement purposes ......................................................
$___________________
Indicate percentage _____________%
6. Total 2014–2015 employee earnings ..................................................................................... $___________________
CONTRIBUTIONS
7. Employee contributions — regular (taxed) .............................................................................. $___________________
8. Employee contributions — picked up (tax-deferred) .............................................................. $___________________
9. Total 2014–2015 employee contributions* (12% of total 2014–2015 earnings on line 6) ...
$___________________
*These contributions should agree with those reported on the 2014–2014 Annual Report.
SERVICE CREDIT AND CONTRACT INFORMATION
10. Service credit earned in 2014–2015 ......................................................................................... ____________________%
11. Last payroll date ________________________________________________________________________________.
12. Last day employee worked (including used sick days or used vacation) _____________________________________.
13. Position held ___________________________________________________________________________________.
14. Contract salary (please supply full contract amount even if not completed) ..................... $___________________
15. Beginning and ending dates of full contract ____________________________to _____________________________.
Number of days in total contract (even if not completed) _________________.
16. Percentage increase generally granted to teaching employees ................................................ ____________________%
TO BE CERTIFIED BY TREASURER OR PAYROLL OFFICER
I certify that the information provided on this report is accurate and, as of the above retirement date, this member has
terminated employment.
Certified by ________________________________________________________ Date _________________________
Title ______________________________________________________________ Phone (_______) _______________
Area code
50-103b, 4/14/1
v. 14–15