Monthly Remittance Report (Form #50.W)

Employer Number Employer Name Contributions deducted for the month of Due the end of

Interest charged for late remittance period Interest charged amount

Regular Contributions	Employee Contributions	Employer Contributions	Total Contributions
Pension Contributions	$+	$=	$
Disability Contributions	$+	$=	$

Insurance Contributions	Employee Contributions	Employer Contributions	Total Contributions
Basic Life	$+	$=	$
Optional Life - No. of Employees Participating:			$
Family Life - No. of Employees Participating:			$
Voluntary Accidental Death & Dismemberment (AD & D)			$
Employee Only Plan - No. of Employees Participating:
Family Plan - No. of Employees Participating:
Manitoba Retail Sales Tax on Insurance Contributions			$

*Attach a list of the employees that participate in the buyback of service

ADJUSTMENTS - Please attach a written explaination as to why the adjustments required and to which employees they apply. **Important Note - adjustments for Basic Life, Optional Life, Family Life, or Voluntary AD&D insurance, are subject to Manitoba provincial sales tax (rst).

Period	Pension		Disability		Basic Life		Total
(MM/YYYY)	Employee	Employer	Employee	Employer	Employee	Employer
	$	$	$	$	$	$	$
	$	$	$	$	$	$	$
	$	$	$	$	$	$	$
	$	$	$	$	$	$	$

Period	Optional Life	Family Life	Voluntary AD&D	MB rst ON	Total
(MM/YYYY)	Employee	Employee	Employee	INSUR CONTR
	$	$	$	$	$
	$	$	$	$	$
	$	$	$	$	$
	$	$	$	$	$
TOTAL ADJUSTMENTS					$

GRAND TOTAL (MUST MATCH CHEQUE AMOUNT)

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