Name of the person completing this form *

First Name

Last Name

Cleric Name *

First Name

Last Name

Church employer contributes to Clergy Pension *

Yes

No, our cleric is retired

Other (describe below)

Does employer contribute to cleric's health insurance premium? *

Yes, we pay 100% of the premium

Yes, we pay 80% of the premium

Yes, we pay a different amount of the premium (describe below)

No, the cleric has coverage through spouse's employment

No, the cleric has coverage through another source

No, cleric is employed less than 50% time and is not eligible

Other (describe below)

If this cleric was newly hired in 2022, what was their start date?

MM

DD

YYYY

If this cleric is no longer employed by your church, what was their termination date?

MM

DD

YYYY