TN 94 (06-04)
SI 00830.541 Uniformed Services – Worksheets for Benefits Payable Prior to June 1, 2004
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.
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
Enter the same months at the top of the "Received in" columns as were entered in the "LES Work Month" columns.
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.
Total the entries to obtain chargeable earned and unearned income for each month.
No rounding of income or input entries, SI 02001.010A.2. - SI 02001.010A.3.
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.
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UNIFORMED SERVICES MONTHLY INCOME (Non-Army)
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
Total Nonsubsistence Allowances and Special Pay
Net Pay Midmonth
Net Pay First-of-Month
SECTION II: CALCULATIONS (Carry to 3 decimal places.)
B ÷ 2
D – F
564.020 – 83.235
E – F
569.390 – 83.235
G + H
480.785 + 486.155
G ÷ J
480.785 ÷ 966.940
K x A
A – L
808.800 – 401.973
K x C
287.340 x .497
C – N
287.340 – 142.807
F + N
83.235 + 142.807
F + O
83.235 + 144.533
SECTION III: CHARGEABLE INCOME BY MONTH OF RECEIPT
Received in Month 1
Received in Month 2
Received in Month 3
Received in Month 4
*CARRIED OVER FROM COLUMN 4 OF PRIOR WORKSHEET