WC-1
Rev. 05/09
Calculations
Florida Retirement System Pension Plan
Certification of Workers' Compensation
P O Box 9000
Tallahassee FL 32315-9000
850 488-6491 Toll Free 888 738-2252
Fax 850 410-2195
Member Name: Member SSN:
Instructions: The information below is needed to accurately credit this account for any period of Workers' Compensation.
Please attach copies of supporting documents such as Notice of Injury, Notice of Beginning or Suspension of Compensation,
Final Orders and other documents showing dates of maximum medical improvement (MMI). Please complete the chart and
requested information below. If you fax this form, do not mail the original.
Date of Injury:
Dates of Temporary Total or Temporary Partial Payments:
Maximum Medical Improvement Date:
Rate of pay when Workers' Compensation payments began: $ per month
Did this employee return to work in a regularly established position?
Yes
No
Date returned to work:
Date terminated:
From to
The following certification of salaries represents the difference in the member's normal rate of pay minus the actual amount of
any salary paid for periods of temporary total and temporary partial dates. Appropriate retirement contributions for the
difference should be reported on the next retirement report. Please refer to the employer handbook, Chapter 2.
Employee Pay Period: Biweekly ( ) Monthly ( ) Semimonthly ( )
Pay Period
End Date
Check
Date
Rate of Pay Salary Paid Difference Pay Period
End Date
Check
Date
Rate of Pay Salary Paid Difference
E-mail Address:
()
If yes, which month were they reported?
Who should we contact for questions regarding the above reporting?
If no, which month will they be reported?
Have salaries been reported to the Division on the payroll report?
Agency Number:
Name:
Certified by and Title:
Agency Phone: ( ) Date: / /
Phone:
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