Employer Name* Town/City* State* Zip* Employer Account Number*
Print Name of Authorized Church/Emploer Representative* Telephone Number* Email Address*
Signature of Authorized Church/Emploer Representative* Date Form Completed* Effective Date of Changes*
Employer Name Town/City State Zip Employer Account Number
Print Name of Authorized Church/Emploer Representative Telephone Number Email Address
Signature of Authorized Church/Emploer Representative Date Form Completed (mm/dd/yyyy) Effective Date of Changes (mm/dd/yyyy)
Compensation Information (Please round to the nearest dollar. This form may be photocopied if more than 8 employees are having compensation changes.)
Member Name
(list only employees who have a compensation change)
Social Security Number
Annual Cash Salary
(Parsonage AND OR Housing Allowance)
Social Security/Medicare Oset
Total Annual Compensation
Sum of parsonage
rental value,
parsonage and
utilities allowance
Housing allowance
Dollar amount
Include in
Comprehensive Plan
premium calculation?
A18 M0116
Please return this completed form to:
MMBB Financial Services
475 Riverside Drive, Suite 1700 New York, NY 10115-0049
Phone: 800.986.6222 Fax: 800.986.6782 Web: www.mmbb.org
*Include amounts to be withheld for Member Contribution Plan and Flexible Spending Account
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Employer Information
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To Request Billing Changes This Form Must Be Returned To MMBB
1. Only an authorized Church/Employer representative (an individual authorized to report changes on behalf of the church) should report
all compensation changes for employees who are participating in the Comprehensive Plan, Retirement Only, or the Member Contribution
Plan using one of the following:
a. Mail this form to MMBB Financial Services at 475 Riverside Drive, Suite 1700 New York, NY 10115.
b. Email this form to forms@mmbb.org.
c. Fax this form to the attention of Billing at 800.986.6782.
d. Any questions, please call a Senior Benefit Specialist at 800.986.6222.
Please do not send billing changes to the lockbox address in Dallas.
2. If there are any changes in the amount of contributions for the Member Contribution Plan, a new Salary Reduction Agreement form (A-13a)
must be completed.
3. If there are any changes to contributions for the Retirement Only Plan, a Change of Contribution form (A-13b) must be completed.
New Enrollment in the Retirement Only Plan or the Member Contribution Plan
When a member enrolls in either of these plans for the first time, a Membership Application form (A-1) must be completed. In addition when
enrolling in the Member Contribution Plan, a Salary Reduction Agreement form (A-13a) is also required.
Special Note for Clergy
Clergy who wish to enroll in the Member Contribution Plan must have reported cash compensation. In addition there is an IRS limit to the
amount of employer contributions available to clergy reporting 100% of compensation as housing allowance. Please contact a Senior Benefits
Specialist for details.
To request any of the forms noted above, email us at service@mmbb.org or call us toll free.
Billing Reminders