PLAN A MONTHLY REPORT OF EARNINGS AND CONTRIBUTIONS RATES EFFECTIVE 7/01/17 THROUGH 6/30/18 REPORT DUE BY 10TH OF MONTH SAMPLE

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3 PLAN A Municipal Employees' Retirement System of LA (MERS) 7937 Office Park Boulevard Baton Rouge, LA Phone: * Toll Free: * Fax: MONTHLY REPORT OF EARNINGS AND CONTRIBUTIONS RATES EFFECTIVE 7/01/17 THROUGH 6/30/18 REPORT DUE BY 10TH OF MONTH Municipality Name and Address Month Reported: Monthly DROP Included Supplemental % of Total Wages - Employer Contributions Total Covered Wages (COLUMN 8) Covered wages include regular earnings, paid holidays, and leave. Do not include overtime, bonuses, workmen's compensation or lump sum leave payments. 9.50% of Total Wages - Employee Contributions (COLUMN 9) Adjustment for overpayment or underpayment of Employee Contributions (Must remit a copy of MERS' approval letter) Adjustment for overpayment or underpayment of Employer Contributions (Must remit a copy of MERS' approval letter) 6. TOTAL - Lines 2, 3, 4, & 5 ACH Check Pay Period Dates Included in Report Total Employees Reported: SUMMARY OF DETAILED PAGE(s) SAMPLE to I HEREBY CERTIFY THAT THE INFORMATION SHOWN IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE: Signature of Clerk or Designated Authority: Form A Revised 7/2017

4 PLAN A 6. SOCIAL SECURITY NUMBER 7. EMPLOYEE NAME (Alphabetical-Last Name First) TOTAL FOR THIS PAGE Municipal Employees' Retirement System of LA (MERS) RATES EFFECTIVE 7/01/17 THROUGH 6/30/18 SAMPLE 8. COVERED WAGES 9. EMPLOYEE CONTRIBUTION 9.50% 3 Form A Revised 7/2017

5 PLAN A - DROP Municipal Employees' Retirement System of LA (MERS) 7937 Office Park Boulevard Baton Rouge, LA Phone: * Toll Free: * Fax: MONTHLY REPORT OF EARNINGS AND CONTRIBUTIONS RATES EFFECTIVE 7/01/17 THROUGH 6/30/18 REPORT DUE BY 10TH OF MONTH Municipality Name and Address Month Reported: % of Total Wages - Employer Contributions 3. Total Covered Wages (COLUMN 8) Covered wages include regular earnings, paid holidays, and leave. Do not include overtime, bonuses, workmen's compensation or lump sum leave payments. Adjustment for overpayment or underpayment of Employer Contributions (Must remit copy of MERS' approval letter) 4. TOTAL - Lines 2 & 3 ACH CHECK Total Employees Reported: D R O P R E P O R T Pay Period Dates Included in Report SUMMARY OF DETAILED PAGE(s) SAMPLE to I HEREBY CERTIFY THAT THE INFORMATION SHOWN IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE: Signature of Clerk or Designated Authority: Form A-D Revised 7/2017

6 SOCIAL SECURITY NUMBER TOTAL FOR THIS PAGE PLAN A - DROP Municipal Employees' Retirement System of LA (MERS) RATES EFFECTIVE 7/01/17 THROUGH 6/30/18 7. EMPLOYEE NAME (Alphabetical-Last Name First) SAMPLE 8. COVERED WAGES 9. EMPLOYER CONTRIBUTION 24.75% 4 Form A-D Revised 7/2017

7 PLAN B Municipal Employees' Retirement System of LA (MERS) 7937 Office Park Boulevard Baton Rouge, LA Phone: * Toll Free: * Fax: MONTHLY REPORT OF EARNINGS AND CONTRIBUTIONS RATES EFFECTIVE 7/01/17 THROUGH 6/30/18 REPORT DUE BY 10TH OF MONTH Municipality Name and Address Month Reported: Monthly DROP Included Supplemental % of Total Wages - Employer Contributions Total Covered Wages (COLUMN 8) 5% of Total Wages - Employee Contributions (COLUMN 9) Total Employees Reported: SUMMARY OF DETAILED PAGE(s) Covered wages include regular earnings, paid holidays, and leave. Do not include overtime, bonuses, workmen's compensation or lump sum leave payments. Adjustment for overpayment or underpayment of Employee Contributions (Must remit a copy of MERS' approval letter) Adjustment for overpayment or underpayment of Employer Contributions (Must remit a copy of MERS' approval letter) Pay Period Dates Included in Report SAMPLE to 6. TOTAL - Lines 2, 3, 4, & 5 ACH CHECK I HEREBY CERTIFY THAT THE INFORMATION SHOWN IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE: Signature of Clerk or Designated Authority: Form B Revised 7/2017

8 PLAN B 6. SOCIAL SECURITY NUMBER 7. EMPLOYEE NAME (Alphabetical-Last Name First) TOTAL FOR THIS PAGE Municipal Employees' Retirement System of LA (MERS) RATES EFFECTIVE 7/01/17 THROUGH 6/30/18 SAMPLE 8. COVERED WAGES 9. EMPLOYEE CONTRIBUTION 5% 5 Form B Revised 7/2017

9 PLAN B - DROP Municipal Employees' Retirement System of LA (MERS) 7937 Office Park Boulevard Baton Rouge, LA Phone: * Toll Free: * Fax: MONTHLY REPORT OF EARNINGS AND CONTRIBUTIONS RATES EFFECTIVE 7/01/17 THROUGH 6/30/18 REPORT DUE BY 10TH OF MONTH Municipality Name and Address Month Reported: % of Total Wages - Employer Contributions 3. Total Covered Wages (COLUMN 8) Covered wages include regular earnings, paid holidays, and leave. Do not include overtime, bonuses, workmen's compensation or lump sum leave payments. Adjustment for overpayment or underpayment of Employer Contributions (Must remit copy of MERS' approval letter) 4. TOTAL - Lines 2 & 3 ACH CHECK I HEREBY CERTIFY THAT THE INFORMATION SHOWN IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE: Signature of Clerk or Designated Authority: Total Employees Reported: D R O P R E P O R T Pay Period Dates Included in Report SUMMARY OF DETAILED PAGE(s) SAMPLE to Form B-D Revised 7/2017

10 SOCIAL SECURITY NUMBER TOTAL FOR THIS PAGE PLAN B - DROP Municipal Employees' Retirement System of LA (MERS) RATES EFFECTIVE 7/01/17 THROUGH 6/30/18 7. EMPLOYEE NAME (Alphabetical-Last Name First) SAMPLE 8. COVERED WAGES 9. EMPLOYER CONTRIBUTION 13.25% 6 Form B-D Revised 7/2017

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65 PLAN A Municipal Employees' Retirement System of LA (MERS) 7937 Office Park Boulevard Baton Rouge, LA Phone: * Toll Free: * Fax: Municipality Name and Address % of Total Wages - Employer Contributions Total Covered Wages (COLUMN 8) MERS' RETIREES RETURNED TO WORK THIS FORM IS TO BE USED FOR MERS' RETIREES WHO FIRST RETURN TO WORK ON OR AFTER 7/01/2016. RATES EFFECTIVE 7/01/17 THROUGH 6/30/18 REPORT DUE BY 10TH OF MONTH Month Reported: Covered wages include regular earnings, paid holidays, and leave. Do not include overtime,bonuses, workmen's compensation or lump sum leave payments. 9.50% of Total Wages - Employee Contributions (COLUMN 9) Adjustment for overpayment or underpayment of Employee Contributions (Must remit a copy of MERS' approval letter) Total Employees Reported: SUMMARY OF DETAILED PAGE(s) Adjustment for overpayment or underpayment of Employer Contributions (Must remit a copy of MERS' approval letter) Pay Period Dates Included in Report SAMPLE to 6. TOTAL - Lines 2, 3, 4, & 5 ACH CHECK I HEREBY CERTIFY THAT THE INFORMATION SHOWN IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE: Signature of Clerk or Designated Authority: RETURN TO WORK EARNINGS form must be attached to this report. Form A-RTW Revised 7/2017

66 SOCIAL SECURITY NUMBER TOTAL FOR THIS PAGE PLAN A - RTW RETIREE Municipal Employees' Retirement System of LA (MERS) RATES EFFECTIVE 7/01/17 THROUGH 6/30/18 7. EMPLOYEE NAME (Alphabetical-Last Name First) 8. COVERED WAGES 9. EMPLOYEE CONTRIBUTION 9.50% RETURN TO WORK EARNINGS form must be attached to this report. SAMPLE 40 Form A-RTW Revised 7/2017

67 MUNICIPAL EMPLOYEES' RETIREMENT SYSTEM OF LOUISIANA 40 RETURN TO WORK AFTER RETIREMENT GROSS MONTHLY EARNINGS FROM 1ST OF MONTH THROUGH 31ST DATE: RETIREE NAME: SSN: MUNICIPALITY MONTH OF: MONTHLY GROSS EARNINGS: Do not use pay periods. Use 1st through 31st of month only Signature of Designated Authority For Office Use Only Date Retired: FAC at Retirement: Current FAC: Monthly Earnings Limit: Current Benefit: Benefit Adjustment: Offset Amount: Adjusted Benefit: Effective Date: End Date: SAMPLE Calculated By: Checked By: Form A-RTW Revised 10/2016

68 PLAN B Municipal Employees' Retirement System of LA (MERS) 7937 Office Park Boulevard Baton Rouge, LA Phone: * Toll Free: * Fax: Municipality Name and Address % of Total Wages - Employer Contributions MERS' RETIREES RETURNED TO WORK THIS FORM IS TO BE USED FOR MERS' RETIREES WHO FIRST RETURN TO WORK ON OR AFTER 7/01/2016. Total Covered Wages (COLUMN 8) RATES EFFECTIVE 7/01/17 THROUGH 6/30/18 REPORT DUE BY 10TH OF MONTH Month Reported: 5% of Total Wages - Employee Contributions (COLUMN 9) Pay Period Dates Included in Report Total Employees Reported: SUMMARY OF DETAILED PAGE(s) Covered wages include regular earnings, paid holidays, and leave. Do not include overtime,bonuses, workmen's compensation or lump sum leave payments. SAMPLE Adjustment for overpayment or underpayment of Employee Contributions (Must remit a copy of MERS' approval letter) Adjustment for overpayment or underpayment of Employer Contributions (Must remit a copy of MERS' approval letter) to 6. TOTAL - Lines 2, 3, 4, & 5 ACH CHECK I HEREBY CERTIFY THAT THE INFORMATION SHOWN IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE: Signature of Clerk or Designated Authority: RETURN TO WORK EARNINGS form must be attached to this report. Form B-RTW Revised 7/2017

69 SOCIAL SECURITY NUMBER TOTAL FOR THIS PAGE PLAN B - RTW RETIREE Municipal Employees' Retirement System of LA (MERS) RATES EFFECTIVE 7/01/17 THROUGH 6/30/18 7. EMPLOYEE NAME (Alphabetical-Last Name First) 8. COVERED WAGES 9. EMPLOYEE CONTRIBUTION 5% RETURN TO WORK EARNINGS form must be attached to this report. SAMPLE 41 Form B-RTW Revised 7/2017

70 MUNICIPAL EMPLOYEES' RETIREMENT SYSTEM OF LOUISIANA 41 RETURN TO WORK AFTER RETIREMENT GROSS MONTHLY EARNINGS FROM 1ST OF MONTH THROUGH 31ST DATE: RETIREE NAME: SSN: MUNICIPALITY MONTHLY GROSS EARNINGS: MONTH OF: Do not use pay periods. Use 1st through 31st of month only Signature of Designated Authority For Office Use Only Date Retired: FAC at Retirement: Current FAC: Monthly Earnings Limit: Current Benefit: Benefit Adjustment: Offset Amount: Adjusted Benefit: Effective Date: End Date: SAMPLE Calculated By: Checked By: Form A-RTW Revised 10/2016

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74 Municipal Employees' Retirement System of Louisiana 7937 Office Park Boulevard, Baton Rouge, LA Toll Free Fax RE EMPLOYED RETIREE OF MERS NAME: ADDRESS: SOCIAL SECURITY NO. Last 4 digits NAME OF EMPLOYER: DATE OF RE EMPLOYMENT: POSITION: CIRCLE ONE: FULL TIME PART TIME I, hereby acknowledge that by returning to work fulltime, my retirement benefit will be suspended. Should I work for twelve (12) months that I shall receive a supplemental benefit for each year of service credit earned during my re employment after retirement. The supplemental benefit will be calculated using my average salary earned during my re employment and the payment option elected on my original retirement benefit. Further, that should I not be reemployed for the required minimum twelve (12) months, that upon application, the system will return my contributions paid during re employment without interest. SAMPLE Further, should I return to work part time, I will be subject to earnings limits according to LA R.S. 11:1762 (2). I shall not accrue additional service credit nor receive a supplemental benefit. Upon termination of my re employment, and upon application, the system will return my contributions paid during reemployment without interest. Signature of retired re employed employee Date Signature of Authorized Representative Date Retiree RTW

75 44 Municipal Employees' Retirement System of Louisiana 7937 Office Park Boulevard, Baton Rouge, LA Toll Free Fax RETIRE FROM FULL TIME RE EMPLOYMENT NAME: SSN: EMPLOYER: FINAL TERMINATION DATE: PLEASE ATTACH AN UPDATED DIRECT DEPOSIT FORM AND A BLANK, VOIDED CHECK. DATE: Retiree Signature Signature of Authorized Representative SAMPLE DATE: Retire from full-time re-employment