Form 202 Annual Budget - Sc Firefighters Association
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4 Firemen’s Insurance and Inspection Fund (1%)
Annual Budget Form
South Carolina State Firefighters’ Association
Date of Request
FORM 202 ‐ Annual Budget
Calendar Year ___________
Fire Department Information (Please print or type)
Fire Dept Name:
Fire Dept ID #:
County:
Fire Dept Contact Name:
Contact Daytime Phone:
Contact Email Address:
and Insurance
A. Retirement
Retirement System
$
Association Plan Contribution
Non‐Association Plan a. Plan Administrator Name
$
b. Contribution Amount
Total Retirement System
$
0
We the undersigned South Carolina Fire Department (“Department”) hereby requests approval, pursuant to
South Carolina Code of Laws 23‐9‐450, that the Supervisory Committee of the South Carolina State Firefighters’
Association (“SCSFA”) approve the expenditure in the amount requested above, to our Department retirement
plan(s). The Department hereby acknowledges and certifies that its retirement plan(s) i) if for paid firefighters, is
qualified pursuant to Internal Revenue Code 401(a); ii) if for volunteer firefighters, is a length of service awards
program, (LOSAP) adopted and exempt from provisions of Internal Revenue Code 457; iii. Comply with South Carolina
Code of Law 23‐9‐460; iv) all future contributions to the Department plan(s) will remain in compliance with the
certifications herein unless the SCSFA is notified in writing to the contrary.
Group Insurance
Company Name:
Insurance Type:
Number of Participants:
$
Total Insurance
TOTAL RETIREMENT AND INSURANCE
$
0
Form 202 Revised 12‐29-2015
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