TN 94 (06-04)

SI 00830.541 Uniformed Services – Worksheets for Benefits Payable Prior to June 1, 2004

A. Introduction

Form SSA-3991 and form SSA-3992 guide the user through the calculation of monthly earned and unearned income using a leave and earnings statement (LES), as explained in SI 00830.540G. Use of these worksheets is optional.

The worksheet (or PC program) is not needed when the service member is paid only once a month.

B. Procedure

1. Heading

Enter the names, Social Security number, and page number at the top of the form.

Then enter the consecutive LES work months (i.e., the calendar months and years of work).

2. Section I

Enter the verified amounts of pay from the LES for each work month requested.

NOTE: The "Net Pay First-of-Month" entry refers to the second  regular payment for the work month, usually issued on the first day of the following month.

3. Section II

Perform the calculations (described in the first column) within each of the columns headed by a work month. Carry each result to 3 decimal places, dropping the fourth digit, if any.

4. Section III

  1. Enter the same months at the top of the "Received in" columns as were entered in the "LES Work Month" columns.

  2. Enter the amounts from the requested cells in Section II (and from the previous worksheet used, if any).
    NOTE: In Section III, all cell names in column 1 that begin with "4" are carry-over amounts from the last column of a previous worksheet.

  3. Total the entries to obtain chargeable earned and unearned income for each month.

C. Reference

No rounding of income or input entries, SI 02001.010A.2. - SI 02001.010A.3.

D. Exhibits

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.

G-SI_00830.541D-1

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G-SI_00830.541D-2

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                                    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


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0500830541
SI 00830.541 - Uniformed Services - Worksheets for Benefits Payable Prior to June 1, 2004 - 08/26/2014
Batch run: 08/26/2014
Rev:08/26/2014