If you choose to use either the SSA-3991 or the SSA-3992, you must reproduce the appropriate
exhibit below; the forms will not be available by order.
The completed example below illustrates use of the SSA-3992 in the situation described
in SI 00830.540G.4.
UNIFORMED SERVICES MONTHLY INCOME (Non-Army)
CLAIMANT/RECIPIENT________________________A/N________________________________
SERVICE MEMBER____________________________Page ____ of ____
|
LES Work Month 1
____/____
|
LES Work Month 2
____/____
|
LES Work Month 3
____/____
|
LES Work Month 4
____/____
|
SECTION I: PAY AMOUNTS FROM THE LES
Basic Pay
|
1A 808.800
|
2A
|
3A
|
4A
|
Total Subsistence
|
1B 166.470
|
2B
|
3B
|
4B
|
Total Nonsubsistence Allowances and Special Pay
|
1C 287.340
|
2C
|
3C
|
4C
|
Net Pay Midmonth
|
1D 564.020
|
2D
|
3D
|
4D
|
Net Pay First-of-Month
|
1E 569.390
|
2E
|
3E
|
4E
|
SECTION II: CALCULATIONS (Carry to 3 decimal places.)
B ÷ 2
166.470÷ 2
|
1F
83.235
|
2F
|
3F
|
4F
|
D – F
564.020 – 83.235
|
1G
480.785
|
2G
|
3G
|
4G
|
E – F
569.390 – 83.235
|
1H
486.155
|
2H
|
3H
|
4H
|
G + H
480.785 + 486.155
|
1J
966.940
|
2J
|
3J
|
4J
|
G ÷ J
480.785 ÷ 966.940
|
1K
.497
|
2K
|
3K
|
4K
|
K x A
.497 x808.800
|
1L
401.973
|
2L
|
3l
|
4l
|
A – L
808.800 – 401.973
|
1M
406.827
|
2M
|
3M
|
4M
|
K x C
287.340 x .497
|
1N
142.807
|
2N
|
3N
|
4N
|
C – N
287.340 – 142.807
|
1O
144.533
|
2O
|
3O
|
4O
|
F + N
83.235 + 142.807
|
1P
226.042
|
2P
|
3P
|
4P
|
F + O
83.235 + 144.533
|
1Q
227.768
|
2Q
|
3Q
|
4Q
|
SECTION III: CHARGEABLE INCOME BY MONTH OF RECEIPT
Received in Month 1
_10/92____
EARNED INCOME
4M*: --
+1L: 401.97_
Total:401.97
UNEARNED INCOME
4Q*: --
+1P:_226.04____
Total: 226.04
|
Received in Month 2
___11/92____
EARNED INCOME
1M: --
+2L:_401.97
Total:401.97
UNEARNED INCOME
1Q: 227.76
+2P:_226.04____
Total:453.80
|
Received in Month 3
____/____
EARNED INCOME
2M:
+3L:____
Total:
UNEARNED INCOME
2Q:
+3P:____
Total:
|
Received in Month 4
____/____
EARNED INCOME
3M:
+4L:____
Total:
UNEARNED INCOME
3Q:
+4P:____
Total:
|
*CARRIED OVER FROM COLUMN 4 OF PRIOR WORKSHEET
FORM SSA-3992