Ps Form 8039 - Back Pay Decision/settlement Worksheet Page 2
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3C. Dollar ($) Amount(s) to Be Offset
1. Receipt of Unemployment Compensation During Back Pay Period?
2. Gross Earnings Received in Outside Employment (NOTE: If self
employed, only report net earnings.)
Yes (See below)
No
Paying State:
Yes (See below)
No
Date From
Date To
Amount Received
Date From
Date To
Amount Received
3a. Receipt of a Terminal Leave Payment (Attach Form 2246 or other applicable documentation)
3b. If Leave Was Overdrawn, Was a Bill Established?
Yes
No
Yes (See below)
No
Gross Terminal Leave Payment
Date Paid
Number of Annual Leave Hours
D. Benefit Election(s)
1. Health Insurance (Check only one)
2. Life Insurance (Check only one)
Enroll as New Employee
Retroactive Reinstatement
Enroll as New Employee
Retroactive Reinstatement
If Checked, Complete
If Checked, Complete
the Following:
the Following:
Plan Code _______________
Enrollment Continued
Plan Code _______________
Enrollment Continued
(Never terminated)
(Never terminated)
Effective Date ____________
No Coverage
Effective Date ____________
No Coverage
3. Thrift Savings Plan (Check only one)
NOTE: Employees May Not Increase Their Life Insurance Coverage
Unless They Meet the Conditions Specified in ELM 436.427.
4. Leave Benefits - Indirect Calculations Only (Check only one)
Enroll as New Employee
Retroactive Reinstatement
Full Leave Benefits
Partial Leave Benefits
If Checked, Complete
No Participation
If Partial Leave Benefits, Explain:
the Following:
Contribution Rate __________ % or $ __________ per P/P
NOTE: Back Pay Based on the Direct Calculation Method Assumes
NOTE: Attach a Copy of TSP
Employee Is Entitled to Full Leave Benefits. Annual Leave Will Be
Election Form(s) Covering
Effective Date ____________
Credited Up to the MAXIMUM CARRYOVER Allowed Unless Otherwise
the Back Pay Period.
Specified in the Settlement.
5. Retirement Benefits
Yes (See below)
No
Beginning and End Dates
Calculate Retirement Benefits
for Retirement Service Credit: ___________________________
Based on Hours per P/P: ___________________________
E. Salary Progression (If award is to make whole, step deferments for LWOP during back pay period should be cancelled. Submit
data only in the following format. A copy of service history is not acceptable.)
NOA
NOA Description
Effective Date Des/Act Code
RSC
Level/Step
Salary
COLA
Attach Additional Sheets as Necessary Using This Format.
8039
PS Form
, November 1996 (Page 2 of 3)
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Parent category: Life