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K-12 RETIREE SUBSIDY WORKSHEETEFFECTIVE OCTOBER 1, 2019School District/ESD NameSchool District/ESD NumberMonth/Year of ReportReporting Methodology:A.S275 & S277 BasisBased on SPI Prior Year or Estimate (October - December)Based on SPI Current Year Report (January - September)B.Monthly ActualsPlease fill in the section below that corresponds with the method selected.Method A:S275 (Certified Eligible Employees)Full-Time Staffx69.56==J22*H22Part-Time Employees Receiving:Equal to or more than 87.5% of Benefitsx=J22==J24*H2462.5% to 87.49% of Benefitsx=J22*75%==J25*H2537.5% to 62.49% of Benefitsx=J22*50%==J26*H2612.5% to 37.49% of Benefitsx=J22*25%==J27*H27 Subtotal: S275 Subsidy Due=SUM(L22:L27)S277 (Classified Eligible Employees)Full-Time Staffx=J22==J32*H32Part-Time Employees Receiving Equal to or more than 87.5% of Benefitsx=J32==J33*H3362.5% to 87.49% of Benefitsx=J22*75%==J34*H3437.5% to 62.49% of Benefitsx=J22*50%==J35*H3512.5% to 37.49% of Benefitsx=J22*25%==J36*H36Subtotal: S277 Subsidy Due=SUM(L32:L36)Adjustment of October - December EstimatesJanuary Only/Method A: Attach WorksheetLess Employees Enrolled in PEBB Plansx=J22==J43*H43Total Amount Due for the Month=L40+L38+L29-L43Method B:Number of Full-Time Eligible EmployeesNumber of Part-Time Eligible EmployeesAverage Percentage of Benefits for Part-Time EmployeesNumber of Employees Enrolled in PEBB PlansTotal Amount Due for the MonthI certify that the information in this report is correct and that the financial calculation upon which this report is based is accurate.DateNameTitleWashington State Health Care AuthorityK-12 RETIREE SUBSIDY METHOD A - RECONCILIATIONThis worksheet will determine the January Reconciliation for School Districts using Method A (S275 and S277) by calculating the adjustment of amounts submitted based on estimates for October, November and December. This worksheet should not be used by school districts or ESDs that are calculating the subsidy based upon actual staffing counts on a month-to-month basis (Method B.)Amount Due Per Month Per S275/S277 Calculationxmonths3Adjusted Subsidy for Period October - December=L64*L63Acutal Amount Submitted OctoberAcutal Amount Submitted NovemberAcutal Amount Submitted DecemberAmount Previously Submitted for Period October - December=SUM(H68:H70)Additional Amounts Due (Overpaid) for October - December=L66-L72Add (subtract) the amount shown to the January amounts due on the January report submission.Washington State Health Care AuthorityK-12 Retiree Allocation PaymentsP. O. Box 24142Seattle, WA 98124-0142 ................
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