EMPLOYEE’S STATEMENT RELATIVE TO BACK PAY
This 2 page document must be completed and signed by the employee prior to payment of back pay.
Employee Name:______
Current address:______
City, State, Zip:______
SSN:______
- Did you receive a Lump Sum Annual Leave Payment? If so, state the amount of the payment, the number of hours the payment represents, and date paid.
______
2. Did you withdraw any of your federal retirement funds from OPM during the back pay period? If so, state the amount and date of withdrawal.______
3. Did you elect to retire from Federal service during the back pay period? If so, state the amount of the retirement annuity payments you received and dates paid.
______
4. Did you hold a paying job during the back payperiod to replace lost wages? If so, state dates of employment and provide name, address and telephone number of employer(s) and attach copies of W-2(s) and pay statement(s). State whether you had a 401K at each job and the amount you contributed. Did you reach your annual limit amount?
______
5. Did you receive unemployment compensation during the back pay period? Attach copies of payment vouchers or other documentation showing the payments received.
______
6. Do you wish to have your health insurance reinstated forthe back pay period? If yes, deductions will be taken for each missed premium paymentfrom your back pay award.
______
7. Do you wish to make up any of the Thrift Saving Plan (TSP) deductions you missed during the back payperiod? If so, deductions will be taken for each missed contribution from the back pay award. ______
8. If you were separated from Federal service during the back pay period, did you receive severance pay or a voluntary separation incentive payment (VSIP)? If so, state the date and amount of each payment.
______
9. Were thereany dates during the back pay period that you would have been unable to work due to an incapacitating illness, injury or any other reason?
______
10. Did you receive workers’ compensation during the back pay period? If so, please indicate the dates of payments and amounts received.
______
The above information is true and correct to the best of my knowledge.
______
Employee Printed Name
______
Employee SignatureDate
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