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EMPLOYER CASH REMITTANCE

Please send check(s) and this form to: STRS Ohio, P O. Box 631135, Cincinnati, OH 45263-1135 .

If you use wire transfer or ACH, you can fax this form to (614) 227-4683. If you are submitting contributions for more than one employer, please complete a separate form for each employer. If you have questions, please call STRS Ohio toll-free at 1-888-535-4050 or visit www.strsoh.org/employer.

Section 1 -- Employer Information

Four-digit Employer name _______________________________________________ employer number _________________

Section 2 -- Payment Method and Amount

Check(s)

Total amount $ _____________

Wire transfer*

Date ______________________ Total amount $ _____________

ACH (Automated Clearing House)*

Date ______________________ Total amount $ _____________

*Complete a separate form for each wire transfer or ACH.

Section 3 -- Contribution Amounts Included in Payment

Check number Amount $ ____________________ $ ____________________ $ ____________________ $ ____________________

10% employee contributions

Pay date(s) _________________________

Leave blank if wire transfer or ACH Complete for check(s), wire transfer or ACH

____________________ ____________________

14% employer contributions

Pay date(s) _________________________

____________________ ____________________

Section 4 -- Other Amounts Included in Payment

Check number Amount $ ____________________

3.5% ARP contributions (submit monthly)

(College or university ONLY) Fiscal month ___________________________

Leave blank if wire transfer or ACH Complete for check(s), wire transfer or ACH

____________________

Payroll deduction for purchase of

service credit (submit monthly)

(Submit copy of payroll deduction remittance form) Fiscal month ___________________________

____________________ ____________________ ____________________ ____________________ ____________________

$ ____________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________

Adjustments to member accounts Payment for invoice

(Submit copy of invoice)

Other ______________________________ Other ______________________________

Total of amounts in Sections 3 and 4 should equal the total payment amount listed in Section 2. Date submitted ____________________ Signature ______________________________________________________

50-269

4/12/1

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