Back Pay Decision/Settlement Worksheet

1 back Pay Decision/Settlement WorksheetINSTRUCTIONS: The applicable sections of this form, depending on the calculation method used (see ELM 436), must becompletely filled out before the Minneapolis Accounting Service Center (ASC) can process this back pay claim. The employee mustreview and agree to the information provided on this form prior to submission to the not attach or forward any additional documentation supporting this claim, unless otherwise specified. ALL supportingdocumentation must be retained as a part of the back pay file at the final approval General Information (Must be completed)1. Employee s Name3a. Social Security Number5.

2 Finance Number2. Address of Employing Office4. back Pay Period (From/to: month, day, year)6. Calculation Method (Check only one)7a. Forum of decision /Award or settlement Agreement (Check only one)8. Was Interest EXPRESSLY AWARDED in the decision /Award or settlement Agreement?Direct Calculation:Indirect Calculation:(For separations, suspensions, anddenial. Complete all sections.)(Complete section F. No benefitsare affected unless specified in thedecision. If such is the case, theappropriate data must be noted insections D and H.)Pay Differential:Erroneous Separationfor Optional Retirement(Complete section H. Section E shouldalso be completed if a salary progressionis applicable.)

3 (Complete sections D, E, and G, and youmust attach either: (a) a letter from OPMstating the amount of erroneous paymentsif an annuity has been paid; or (b) a copy ofthe employee s NARECS monthly annuitystatement stating amount of erroneouspayments if no annuity payments werereceived by the employee.)Grievance (Steps 1 through 4)ArbitrationMSPBOPMEEOCC ourtOther:Yes (Interest is computed after the award has been processed and is paid by separate check.)NoB. Periods DisallowedNOTE: A copy of this form must be sent to the San Mateo ASC for the processing and payment of court costs and/or attorney Form 8039, November 1996 (Page 1 of 3)Date FromDate ToAmount ReceivedDate FromDate To$$$2.

4 For Failure to Seek Outside Employment (List dates below)9a. Were Court Costs Awarded?10a. Were Attorney s Fees Awarded?10b. Amount of Fee10c. Name and Address of Attorney9c. Name and Address of Payee9b. Amount AwardedYes (Complete items 9b and 9c)NoYes (Complete items 10b and 10c)No1. For Receipt of Worker s Compensation (Check only one)Full CompensationPartial Compensation3b. Designation/Activity Code$$7b. Date of DecisionC. Dollar ($) Amount(s) to Be OffsetD. Benefit Election(s)E. Salary Progression (If award is to make whole, step deferments for LWOP during back pay period should be cancelled. Submitdata only in the following format. A copy of service history is not acceptable.)

5 PS Form 8039, November 1996 (Page 2 of 3)Attach Additional Sheets as Necessary Using This FromDate ToAmount ReceivedDate FromDate ToAmount Received1. Receipt of Unemployment Compensation During back Pay Period?2. Gross Earnings Received in Outside Employment (NOTE: If selfemployed, only report net earnings.)Paying State:Yes (See below)NoYes (See below)NoGross Terminal Leave PaymentDate PaidNumber of Annual Leave Hours3a. Receipt of a Terminal Leave Payment (Attach Form 2246 or other applicable documentation)Yes (See below)No1. Health Insurance (Check only one)2. Life Insurance (Check only one)4. Leave Benefits - Indirect Calculations Only (Check only one)3. Thrift Savings Plan (Check only one)Enroll as New EmployeeIf Checked, Completethe Following:Retroactive ReinstatementEnroll as New EmployeeIf Checked, Completethe Following:Retroactive ReinstatementEnrollment Continued(Never terminated)Enrollment Continued(Never terminated)No CoverageNo CoverageEffective Date _____Plan Code _____Effective Date _____Plan Code _____NOTE: Employees May Not Increase Their Life Insurance CoverageUnless They Meet the Conditions Specified in ELM as New EmployeeIf Checked, Completethe Following:Retroactive ReinstatementFull Leave BenefitsPartial Leave BenefitsEffective Date _____Contribution Rate _____ % or $ _____ per P/PNo ParticipationNOTE.

6 Attach a Copy of TSPE lection Form(s) Coveringthe back Pay Partial Leave Benefits, Explain:NOTE: back Pay Based on the Direct Calculation Method AssumesEmployee Is Entitled to Full Leave Benefits. Annual Leave Will BeCredited Up to the MAXIMUM CARRYOVER Allowed Unless OtherwiseSpecified in the Retirement BenefitsYes (See below)NoBeginning and End Datesfor Retirement Service Credit: _____Calculate Retirement BenefitsBased on Hours per P/P: _____NOANOA DescriptionEffective Date Des/Act CodeRSCL evel/StepSalaryCOLA3b. If Leave Was Overdrawn, Was a Bill Established?YesNoF. Lump Sum Payment (Reminder: If payment is for wages or base hours, award should not be done as a Lump Sum.)

7 G. Hour Tabulation (If PTF, please submit 13 pay periods prior to removal/separation.)H. Special InstructionsPS Form 8039, November 1996 (Page 3 of 3)Tel. Approving Authority s SignatureCertifying Official s SignatureEmployee s SignatureComplete This Section if a Pay Differential Adjustment Is Involved or Additional Information/Instructions Are Required in Order to Process this BackPay Claim. All Special Instructions as Stated in the decision Must Be Included in this Did the decision /Award or settlement Agreement Specifically Providefor a Lump Sum Payment?2. Is the Lump Sum Payment Exempt from any Payroll Deductions orWithholdings?YesNoNoYesIf YES, State the Amount: $ _____If YES, Identify the Payroll Deductions or Withholdings that Are Exempt:NOTE: For Rural Carriers, Use the Evaluated Hours (or Miles) for the Employee s Additional Sheets as Necessary Using this Hours(52)OT Hours(53)N/W Hours(54)Hol.

8 Work(57)Hol. Leave(58)Sun. Prem.(72)A/L Hours(55)S/L Hours(56)121212121212121212121212121212 NOTE: This Should Only Apply if You Checked Section A6, IndirectCalculation, on Page Tour on Which Employee Would Have Worked: Start Time: End Time:2. Non Scheduled Days:SaturdaySundayMondayTuesdayWednesda yThursdayFriday