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).

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.

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.

1. a. 

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

2. b. 

   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. c. 

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