Clergy Moving Expense Payments by a Local Church

This form is used to report clergy moving expense payments for pension benefit requirement.  

Please provide the name and email of person filling out this form.  

*First Name
*Last Name
*Name of Local Church
*Address of Local Church
*Amount Paid
*Name of Clergyperson
*Date Paid

Please provide this completed form as soon as reasonably feasible, preferably within two weeks of payment but no later than September 30 pf the current year. If you have questions, please contact Debbie Gagnon at (978) 682-8055 ext 121 or email

*REMINDER: This payment amount should be added to Box 2 of W-2 along with other compensation, in same year payment made.

Participant Number (for Conference use only)
Church GCFA (for Conference use only)
Church Conference Number (for Conference use only)
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