Attachment E
CERTIFIED SUMMARY OF
FIREFIGHTER PAY and TOUR
Name: Locality Pay Area:
SSN: Date of Birth:
Instructions to Employing Agency
This worksheet is used to transmit information OPM needs in order to accurately compute
a retiree's benefit.
You must use this worksheet if your agency payroll is not able to post the following items
on the Individual Retirement Record:
An "Annualized Salary" notation under column 4 of the SF 2806, and 3107
The firefighter's tour of duty in effect during the entire high-3 average salary period
The expiration date for any unused sick leave
You must also use this worksheet to reflect any changes in tour during the employee's
high-3 average salary period. This worksheet is also a useful tool for retirement
counseling purposes.
Use the remarks section to document any other pertinent changes (e.g., change in
employee's locality pay area)
Effective Date
of each pay
change:
Grade and Step:
Salary from
Locality Pay
charts:
Salary with
Premium Pay
Included to be
shown on SF 2806
& 3100:
Firefighters weekly tour
(or average hours worked
per week if on rotating
tour):
Date:
Grade and Step:
Salary from
Locality Pay
charts:
Annualized Salary
to be shown on SF
2806 & 3100:
Firefighters weekly tour (or
average hours worked per
Provide Leave Expiration Date for Unused Sick Leave if employee is on an uncommon tour of duty
at retirement:
Remarks:
Agency Certification
I certify that the information shown above
accurately reflects verified information in official
pay records.
Signature:
Official Title:
Telephone Number:
( )
Full agency name and address:
week if on rotating tour):
