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Premium Pay - Biweekly Pay Cap Projection

Employee Name: ______________________________________________
Position Title, Series, Grade: _____________________________________
Agency/Office: _______________________________________________
Type of Emergency (Fire, Flood, etc.): ______________________________
Nature of Work to be Performed: __________________________________
___________________________________________________________
___________________________________________________________

The following information is as of the end of pay period ________________
which covers _________________ (date) through ________________ (date):

Current Base Salary: ___________________________________________
(includes locality-based comparability pay, and/or special salary rate)

Applicable Biweekly Pay Cap: ____________________________________

Applicable Annual Pay Cap: ______________________________________

A. Dollar amount of projected annual base salary if less than either the greater of the biweekly rate payable for a GS-15/10 or Level V of the Executive Schedule (include any projected increase/decrease in base salary, e.g., locality, within-grade, promotion, general increase, change to lower grade, etc.):

    $ ________

B. Dollar amount of annual base salary received to date (beginning with pay period 25 or 26 through end of the current pay period): $ ________

C. Annual base salary remaining to be paid in current calendar year (A minus B): $ ________

D. Total amount of premium pay received to date in current calendar year:

Type Total

Sun-day Differential _________
Sunday Diff w/Night Diff _________
Night Differential _________
Overtime over 8 _________
Overtime over 40 _________
OT over 40 w/Night Diff _________
OT over 8 w/Night Diff _________
Overtime Call-back _________
Holiday Worked _________
Compensatory Time _________
FLSA _________
AUO/Standby/Availability _________

      $ _________

E. Total annual base salary and premium pay received to date and base salary left to be paid in the remainder of the calendar year (B plus C plus D):

$ ________

F. Total amount available for premium pay of any type for the remainder of the current calendar year (annual pay cap minus E): $ ________

CERTIFICATION: I certify that the above figures are correct to the best of my knowledge. I understand that any increases or decreases in my base salary or premium pay entitlements may increase or decrease the amount of additional premium pay I can earn in the remainder of the current calendar year. I also understand that the total of base salary and premium pay I receive may not exceed the greater of the annual rate of basic pay for a GS-15/10 or Level V of the Executive Schedule, in a calendar year. Consequently, if the total of base salary and premium pay I receive at the end of the calendar year exceeds the greater of the annual rate of basic pay of a GS-15/step 10 or Level V of the Executive Schedule, any excess premium pay becomes an overpayment regardless of whether some or all of it was performed in conjunction with an emergency. The amount of the overpayment will be recouped, regardless of administrative error or oversight in the computation above. This statement constitutes evidence of my knowledge of the applicable biweekly and annual pay cap and my responsibility for monitoring premium pay to ensure that premium pay does not exceed the appropriate pay cap. I do not abrogate my right to request a waiver of any overpayment; however, a waiver of overpayment is not likely to be granted as a result of my certification of this statement.

______________________________ __________________________
Employee Date

______________________________ __________________________
First level supervisor Date

______________________________ __________________________
Second level supervisor Date