Monthly Remittance Report (Form #50.W)

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

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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