Monthly Remittance Report (Form RR)

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

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 (Manitoba Residents ONLY)			$
TOTAL REGULAR CONTRIBUTIONS (A)			$

ADJUSTMENTS

Use this section to report PRIOR MONTH/YEAR Adjustments ONLY
You may attach written explanation for the adjustment (why it is required & applicable to what employee)
Adjustments to Group Insurance for MB residents are subject to Manitoba Retail Sales Tax (RST)

Period	Pension		Disability		Basic Life		Total
(yyyy-mm)	Employee	Employer	Employee	Employer	Employee	Employer
	$	$	$	$	$	$	$
	$	$	$	$	$	$	$
	$	$	$	$	$	$	$
	$	$	$	$	$	$	$

Period	Optional Life	Family Life	Voluntary AD&D	MB rst ON	Total
(yyyy-mm)	Employee	Employee	Employee	INSUR CONTR
	$	$	$	$	$
	$	$	$	$	$
	$	$	$	$	$
	$	$	$	$	$
TOTAL ADJUSTMENTS (B)					$

Interest charged for late remittance

Period Interest charged amount (C)

GRAND TOTAL (MUST MATCH DIRECT DEPOSIT OR CHEQUE AMOUNT) = (A) + (B) + (C)

Payment Instruction Cheque Direct Deposit

Cheque - Payable to: Manitoba Municipal Employees Clearing Account. Mail this form and Cheque to: MEBP - PO Box 764, Winnipeg, MB R3C 2L4
Direct Deposit - Email this form before, or on the day of the Bank Deposit to: MEBPadmin@coughlin.ca

Direct Deposit Date (yyyy-mm-dd) OR Cheque Number Contact Person / Form Prepared By Contact Phone Number Date