__ __-__ __/__-__ __ __ __ (Control Number) ________________________ (Date Received) DoDEA Pay Inquiry Worksheet TO: Customer Service Representative (Name)_______________________________________________ Office Location________________________________________________________________________ =========================================================================== Section I - Employee Data 1. EmployeeÕs Name____________________________________ 2. SSN_________________________ 3. HQ Ofc/DSO/School__________________________________________________________________ 4. Telephone No.________________________________FAX No._______________________________ 5. Issues identified in section II and/or III are for pay period(s) ending_____________________________ =========================================================================== Section II - Pay, Allowances Benefits and Other Related Issues Base Pay______ TQSA _______ LQA ______ Post Allowance ______Tropical/Area Differential ______ Retro Pay Adjustment _____ Pay Lane Change _____ Extra Duty Pay _____ Overtime _____ Leave ____ Life Insurance Deductions _____ Health Insurance Deductions _____ Retirement Deductions _____ Identify any issue which has been filed as a grievance:__________________________________________ Other Issues: __________________________________________________________________________ ============================================================================ Section III - EmployeeÕs Description of Pay Problems _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ (Continue on a separate sheet of paper if needed) ============================================================================ Section IV - Customer Service RepresentativeÕs Remarks _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Customer Service RepresentativeÕs Signature and Date: ________________________________________ INSTRUCTIONS FOR PREPARING THE PAY INQUIRY FORM 1. General. Each DoDEA employee is responsible for promptly informing the appropriate Customer Service Representative (CSR) of any pay or pay related deficiencies identified on his or her Leave and Earning Statement (LES). The CSR, in coordination with the Personnel Center Representative (PCR), as required, is responsible for providing prompt assistance in resolving pay issues identified by an employee. This worksheet is to be used to document pay inquiries and related pay issues, as reflected in sections II and III of the worksheet. 2. Section I. Blocks 1, 2, 3 and 4 are self-explanatory. Block 5 should reflect the same pay-period(s) ending date on the LES where the error appears. If a pay-period ending date does not apply, ÒNot ApplicableÓ or ÒN/AÓ should be placed on this line. 3. Section II. Place a check mark beside the item(s) for which the inquiry is being submitted. If a specific pay issue is not shown, use the ÒOther IssuesÓ block to identify and describe the issue. Also, be sure to provide the nature and date of any pay action which was filed as a grievance under a negotiated agreement. 4. Section III. Use this section to write a brief summary of your concerns in relation to the issues(s) you have identified in section II and III. You should describe any efforts you have made to resolve the issue(s), and identify the person(s) with whom they were discussed. Also, use this section to identify or describe any supporting documentation you have attached which may be helpful in expediting the research and resolution of your inquiry (e.g., LES, SF50, SF1190). 5. Section IV. This section is reserved for use by the Customer Service Representative. 6. Where to Send the Pay Inquiry Form: a. Overseas Employees. After the form has been completed, it should be submitted to the CSR, who is collocated with the PCR in your local District SuperintendentÕs Office. b. Stateside Employees. The completed form should be submitted to the CSR at the following address: DoDEA Personnel Center -Team C/CSR Webb Building, 6th Floor 4040 North Fairfax Drive Arlington, Virginia 22203-1634 FACSIMILE NUMBER: 1-(703)-696-4919 7. Assignment of a Control Number for Future Reference: After your pay inquiry worksheet has been received, it will be assigned a control number by your servicing CSR, who will identify this number to you by telephone or cc:Mail. You should keep this number available for use when inquiring the status of your pay inquiry.