APPLICANT’S BENEFITS CALCULATION WORKSHEET



APPLICANT’S BENEFITS CALCULATION WORKSHEET

FEMA DISASTER DECLARATION # FEMA-EM-3192-CT

For snow removal assistance, the fringe rate applicable to force account employees is the Overtime % only.

|BENEFIT |REGULAR TIME % |OVERTIME % |

|FICA | |7.65% |

|Retirement (if applicable) | | |

|Health Insurance | | |

|Life Insurance | | |

|Workers Compensation | | |

|Unemployment Insurance | | |

|Annual Leave | | |

|Sick Leave | | |

|Holiday Leave | | |

|TOTAL: | | |

|COMMENTS: | | |

|I certify that the information above was transcribed from payroll records or other documents which are available for audit. |

|Certified by: |

|Title: |

|Date: |

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