FEDERAL EMERGENCY MANAGEMENT AGENCY
APPLICANT'S BENEFITS CALCULATION
WORKSHEET	PAGE	     	OF	     		
		
1,	APPLICANT
     	2.	PA ID
     	
3.	DISASTER NUMBER
     	4.	PW #
     	
FRINGE BENEFITS (by %)	REGULAR TIME	OVERTIME	
HOLIDAYS	     	     	
VACATION LEAVE	     	     	
SICK LEAVE	     	     	
SOCIAL SECURITY	     	     	
MEDICARE	     	     	
UNEMPLOYMENT	     	     	
WORKER'S COMP.	     	     	
RETIREMENT	     	     	
HEALTH BENEFITS	     	     	
LIFE INS. BENEFITS	     	     	
OTHER	     	     	
TOTAL in % of annual salary	     	     	
COMMENTS
     	
I CERTIFY THAT THE INFORMATION ABOVE WAS TRANSCRIBED FROM PAYROLL RECORDS OR OTHER DOCUMENTS WHICH ARE AVAILABLE FOR AUDIT.	
CERTIFIED BY
     	TITLE
     	DATE
     	
FEMA Form 90-128, NOV 98