Request For Additional Information Form printable pdf download

REQUEST FOR ADDITIONAL INFORMATION

(See reverse side of form for instructions.)

Complete this form only if the member had supplemental earnings in any year from 2009–2010 through 2013–2014 or the member’s contract year was August through July and

the member worked in July. Information on this form will assist us in computing the proper final average salary for retiring members. Please record information for all years in

the appropriate spaces and return this form with the member’s Deposit and Service Report.

Year:

2009–2010

2010–2011

2011–2012

2012–2013

2013–2014

General Information

1. Position member held .............................................. ___________________ ___________________ ___________________ ___________________ ___________________

2. Contract amount ..................................................... $__________________ $__________________ $__________________ $__________________ $__________________

3. Unearned amount for board-approved docked days . $__________________ $__________________ $__________________ $__________________ $__________________

4. Amount of compensation reported during the fiscal

year that was earned in the prior fiscal year ............. $__________________ $__________________ $__________________ $__________________ $__________________

5. Contract specified to begin ..................................... ___________________ ___________________ ___________________ ___________________ ___________________

6. Contract specified to end ........................................ ___________________ ___________________ ___________________ ___________________ ___________________

7. Number of days in contract .................................... ___________________ ___________________ ___________________ ___________________ ___________________

Supplementals or Additional Earnings

8. Pickup included in compensation for retirement

purposes. Indicate percentage .................................. _________________ % _________________ % _________________ % _________________ % _________________ %

9. Earnings for extended days ...................................... $__________________ $__________________ $__________________ $__________________ $__________________

10. Supplemental earnings (please itemize) __________ $__________________ $__________________ $__________________ $__________________ $__________________

___________________________________________ $__________________ $__________________ $__________________ $__________________ $__________________

Complete line 11 only if the member had a contract beginning on Aug. 1 and the member worked under the contract in July. (Colleges and

universities do not need to complete this portion.)

11. Portion of previous year’s contract included in this

fiscal year’s Annual Report ....................................... $__________________ $__________________ $__________________ $__________________ $__________________

For STRS Ohio use only.

Totals: $__________________ $__________________ $__________________ $__________________ $__________________

Recon:

Yes

50-101b, 4/14/1

v. 13–14