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Employee Roster Information

Information Collection Sheet

IMPORTANT: Be sure to include ALL employees of your church, including those who are full-time, part-time, eligible for benefits, ineligible for benefits, etc.

Employee Name(Required)

First Last

Church Name and City(Required)

Person Filling Out Form(Required)

Home Address(Required)

Street Address City State ZIP Code

Mailing Address(Required)

Street Address City State ZIP Code

Home Phone

Mobile Phone(Required)

Work Phone

Email(Required)

Work Email

Individual Client-Number (if known):

SSN (or TaxID):(Required)

Date of Birth:(Required)

MM slash DD slash YYYY

Position:(Required)

Clergy

Lay Employee

Position Title:(Required)

Hire Date (for this position):(Required)

MM slash DD slash YYYY

Type of Position:(Required)

Exempt (Salaried)

Non-Exempt (Hourly)

Unpaid (Volunteer)

Scheduled Hours Worked/Year:(Required)

Compensation:(Required)

Stipendary (Paid)

Non-Stipendary (Unpaid)

Cash Stipend Amount:(Required)

SSN Reimbursement Amount:(Required)

Cash Housing Allowance:(Required)

Total Assessable Compensation:(Required)

Marital Status:(Required)

Single

Married

Divorced

Widowed/Widower

If married, the below spouse information is required to process your information.

If Married, Date of Marriage or Change in Marital Status:

MM slash DD slash YYYY

Spouse's Name

Spouse's Date of Birth:

MM slash DD slash YYYY

Spouse's SSN:

Source of Medical Coverage:(Required)

Employer/Medical Trust

Employer/Non-Medical Trust

Spouse/Partner Plan

Military Plan

Medicare

No Coverage

Other

Level of Medical Coverage:(Required)

Single

Employee +1

Employee + Child(ren)

Family

Percent of medical coverage paid by parish:

Currently Enrolled in which pension program?(Required)

Clergy DB

Lay DB

Lay DC

RSVP

N/A

Employer contributes to pension?(Required)

Yes

No

3700 Woodmont Boulevard
Nashville, Tennessee 37215

PHONE: 615-251-3322
FAX: 615-251-8010
EMAIL: info@edtn.org

Email Address *

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AFFILIATIONS

The Episcopal School of Nashville
St. Andrew’s-Sewanee School
Sewanee: The University of the South
St. Mary’s Sewanee: The Ayres Center for Spiritual Development
The Community of St. Mary — Southern Province
St. Luke’s Community House