Ps Form 8039 - Back Pay Decision/settlement Worksheet Page 3
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3F. Lump Sum Payment (Reminder: If payment is for wages or base hours, award should not be done as a Lump Sum.)
1. Did the Decision/Award or Settlement Agreement Specifically Provide
2. Is the Lump Sum Payment Exempt from any Payroll Deductions or
for a Lump Sum Payment?
Withholdings?
Yes
No
Yes
No
If YES, Identify the Payroll Deductions or Withholdings that Are Exempt:
If YES, State the Amount: $ _____________________________
NOTE: This Should Only Apply if You Checked Section A6, Indirect
Calculation, on Page 1.
G. Hour Tabulation (If PTF, please submit 13 pay periods prior to removal/separation.)
1. Tour on Which Employee Would Have Worked:
Start Time:
End Time:
2. Non Scheduled Days:
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
NOTE: For Rural Carriers, Use the Evaluated Hours (or Miles) for the Employee’s Route.
Work Hours
OT Hours
N/W Hours
Hol. Work
Hol. Leave
Sun. Prem.
A/L Hours
S/L Hours
Year
P/P
Week
Other
(52)
(53)
(54)
(57)
(58)
(72)
(55)
(56)
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Attach Additional Sheets as Necessary Using this Format.
H. Special Instructions
Complete This Section if a Pay Differential Adjustment Is Involved or Additional Information/Instructions Are Required in Order to Process this Back
Pay Claim. All Special Instructions as Stated in the Decision Must Be Included in this Section.
Employee’s Signature
Date
Certifying Official’s Signature
Date
Final Approving Authority’s Signature
Date
Tel. No.
Tel. No.
8039
PS Form
, November 1996 (Page 3 of 3)
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