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If your relief association bylaws provide lump sum benefits, information for questions 7, 10 and 11 may be obtained by <br />completing Schedules I, II, and III. If your bylaws provide monthly annuity benefits, refer to your most recent actuarial <br />survey. If your bylaws provide defined contribution benefits (split- the -pie), complete questions 1 -9. <br />FINANCIAL CONDITION <br />SPECIAL FUND <br />GENERAL FUND <br />ASSETS <br />1. Cash <br />2. Investments <br />3. Accrued Interest Receivable <br />4. Other Receivables <br />5. TOTAL ASSETS <br />LIABILITIES AND FUND BALANCE <br />6. Payables <br />7. Required Reserves (Accrued Liability - Sch. 1, line B, filed by Aug. 1, 1991) <br />8. Surplus or (Unfunded Accrued Liability) /Fund Balance <br />9. Funding Ratio (line 5 - line 6 - line 7) <br />10. Normal Cost - 1991 (Sch. 1, line C, filed by August 1, 1990) <br />11. Required Contribution to Amortize Unfunded Accrued Liability <br />December 31, 1991 <br />AMOUNT <br />)omit cents) <br />1 1 253 <br />2 840,531 <br />3 5 896 <br />4 2 000 <br />5 849 680 <br />6 470 <br />7 889,158 <br />8 (39,948) <br />9 95.51% <br />10 57,263 <br />11 -0- <br />1 <br />2 <br />3 <br />4 <br />5 <br />AMOUNT <br />(Omit Cents) <br />199,317 <br />439 <br />470 <br />200 226 <br />12. Iom(ooge(l ,> DECEMBER 31, 1990 FUND BALANCE <br />12 731,198 <br />12 185,145 <br />REVENUES 1991 <br />AMOUNT <br />AMOUNT <br />13. State Fire Aid <br />14. City Contributions <br />15. Members' Salary Deductions or Contributions <br />16. Members' Dues <br />17. Interest Earned <br />18. Dividends <br />19. Transfers In <br />20. Other (Identify) Gain on sale of investments <br />21. TOTAL REVENUES (lines 13 through 20) <br />13 <br />14 <br />15 <br />16 <br />17 <br />18 <br />19 <br />20 10,491 <br />21 <br />21,023 <br />21,023 <br />64,350 <br />1,125 <br />118,012 <br />13 <br />14 <br />15 <br />16 <br />17 <br />18 <br />19 <br />20 <br />21 <br />xxxxxxxxxxxxxx <br />xxxxxxxxxxxxxx <br />xxxxxxxxxxxxxx <br />14,776 <br />305 <br />15,081 <br />EXPENSES /EXPENDITURES 1991 <br />AMOUNT <br />AMOUNT <br />SERVICE PENSIONS Number <br />22. Retired (Number and Amount) (List names & amounts below) _22 <br />23. Survivors- Spouses and Children (Number and Amount) 23 <br />24. - Permanent Disability (Number and Amount) <br />OTHER BENEFITS <br />25. Sick or Temporary Disability (Number and Amount) <br />26. Death and Funeral (Number and Amount) <br />ADMINISTRATIVE EXPENSES <br />27. Salaries 27 <br />28. Conventions and Meetings 28 <br />29. Dues 29 <br />30. Actuarial Valuation and Audit 30 <br />31. Faithful Performance Bond 31 <br />32. Other (Identify) 32 <br />OTHER <br />33. Transfers Out 33 <br />34. Other (Identify) 34 <br />35. TOTAL EXPENSES /EXPENDITURES (lines 22 through 34) 35 <br />* 22 xxxxxxxxxxxxxx <br />23 xxxxxxxxxxxxxx <br />24 24 xxxxxxxxxxxxxx <br />25 <br />26 <br />25 xxxxxxxxxxxxxx <br />26 xxxxxxxxxxxxxx <br />27 <br />28 <br />29 <br />30 <br />31 xxxxxxxxxxxxxx <br />32 <br />xxxxxxxxxxxxxxxx 33 <br />34 <br />35 <br />36. XXSNYAt XVtSOOMS(DECEMBER 31, 1991 FUND BALANCE <br />(line 12 + line 21 - line 35) 36 849 210 <br />36 <br />200,226 <br />37. Was the Certification of Special Fund Financial Requirements for 1992 (Schedules I, II, III) certified to your municipal governing <br />body (for municipal fire department) or fire department (for independent nonprofit firefighting corporation) by August 1, 1991, in <br />accordance with appropriate general law or special law? L#Yes No Please attach a copy of Schedules I, II, III to this report. <br />• Pensions Paid in 1991 <br />Names <br />3 <br />Amount Paid <br />$ <br />$ Page 58 <br />$ <br />