RPF130

____________________
(Branch)

POSTED TAV OFFSET SCHEDULE (PTOS)

Date __________________________

TAV REMAINING
EMPLOYER'S NAME MEMBER'S NAME EE SHARE ER SHARE TOTAL DIVIDENDS JT DATE
APPLIED TAV
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Employer Count for the page: ___________ Member Count for the page: ____ ____ Total for the page: _______ ___________ ___________ ___________ ___________ ___________

Employer Count for the entire report:__________ Member Count for the entire report:____ General Total: ________ ___________ ___________ ___________ ___________ ___________
(Indicated in the last page) (Indicated in the last page) (Indicated in the last page:)

Prepared by: Reviewed by: Approved by:

________________________ ________________________ ________________________

____ ____ ____