MATT M. ROSENDALE
Commissioner of Insurance & Securities
Office of the State Auditor
840 Helena Ave
Helena, Montana 59601
ANNUAL FINANCIAL REPORT
FILE ON OR BEFORE APRIL 1ST
POLICE RETIREMENT FUND OR POLICE TRAINING AND PENSION FUND
________________________________, Montana ____________________________, 20_______
(City or town) (Date)
Pursuant to the provisions of Section 19-19-204 or 7-32-4120, MCA, we submit the following report of the financial condition
of our Police Retirement Fund or Police Training and Pension Fund for the preceding year ending December 31, .
1. Does your city/town have an established police retirement system governed by a board of trustees, with the
city/town contributing 11% of total salaries in compliance of 19-19-301, MCA?
If YES, check here ( ), and file this annual report pursuant to 19-19-204, MCA.
If NO, check here ( ), and file this annual report pursuant to 7-32-4120, MCA.
2. If your city/town DOES NOT HAVE law enforcement services which qualify for state funding under either of the co
ections mentioned above, check here ( ), sign this report, and return it to the State Auditor’s Office by t
alance on hand per last report: $__________________
Receipts for the year:
Received from State Auditor’s Office $_________________
Received from City _________________
Interest on Investment _________________
Proceeds from local tax levy _________________
Officers’ Contribution from
Salary Deductions _________________
Total Receipts $__________________
Disbursements for the year:
Police Training $________________
Purchase of pensions for members
of Police Department ________________
Other (specify) ________________
Total Disbursements $__________________
alance on hand December 31, 20______ $__________________
I hereby certify the above information is true and correct to the best of my knowledge.
(Signature of Board Member) (Print Name of Board Member and Telephone #
Please list the name and telephone number of a contact person.
(4) Name: (5) Title or Position: (6) Phone #:
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