Pension & Benefit Worksheet

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Employee Pension & Benefit Worksheet

Church of the Lutheran Brethren Pension & Benefit Office

Employee Pension & Benefit Worksheet

Church/Employer Information

Church/Employer Name

Church/Employer Location

City

State

Region

Eastern Region

Central Region

Western Region

Pacific Region

CLBC

Treasurer's Name

Billing Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Benefits Being Provided

Please provide information on all benefits provided to the employee, even if not provided through the CLB synodical offices.

Pension/Retirement Funding

Yes

Health Insurance (select one)

Premium Paid

Stipend Given

None Provided

Health Savings Contribution (HSA)

Yes

Flex Spending Contribution (FSA)

Yes

Supplemental Insurance (check all that apply)

AD&D

Life

LTD

Vision

Dental Insurance

Vacation (please list in days)

Speaking Engagements (please list in days)

Pension Contribution Information

The following information is needed to determine the correct pension billing for your employee. Please use Annual Figures.

Employee's Name

Effective Date of Employment/Salary Change

Minister of the Gospel Compensation (enter the total compensation paid directly to the employee. DO NOT include reimbursement for Self-Employment tax or housing/utility allowance here)

Self-Employment Tax Reimbursement (SECA)

Professional Expense Allowance (These are reimbursements for mileage or other work-related expenses not included in the Minister of the Gospel Compensation)

Is the employee provided a parsonage?

Yes

Parsonage Factor

Housing/Utility Allowance (Enter the amount of Housing Allowance you pay your employee (Even if the employee lives in a parsonage, enter any Housing/Utility Allowance here)

Total Pension Salary (Sum of Compensation, Parsonage, Housing/Utility Allowance)

Monthly Pension Contribution (This number is what will appear on your monthly statement)

Signature Information

Person completing the form

First Name

Last Name

Date

Mailing:
PO Box 655
Fergus Falls, MN 56538

Email: forge@clbforge.org

Phone: 218-739-3336

Username or Email Address

Password

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