Certification for Physicians Comparability Allowances (PCA) Physicians Comparability Allowance received on or after December 28, 2000, is considered basic pay for: · · Computing disability retirement benefits, and Computing survivor benefits for death-in-service For all other retirement computations, employees must have at least 15 years of service as a Government physician before PCA received on or after December 28, 2000, can be considered as basic pay for the average salary computation. The amount of PCA included in basic pay is based on the total amount of service performed as a Government physician on or after December 28, 2000. 1. Name of employee 2. Date of Birth 3. Social Security Number 4. Type of Retirement Action Death (100% of PCA received after 12/27/00 included as basic pay) Disability (100% of PCA received after 12/27/00 included as basic pay) Other Retirement: Voluntary, Early, DSR, Deferred, etc. 5. Has retiree met the 15 year service requirement as a physician? N/A (Death-in-Service or Disability Retirement) No (not eligible for PCA in base pay) Yes (See item 6) 6. PCA payment attributable to service performed on or after December 28, 2000, will be included as basic pay for retirement purposes, based on the total amount of service performed as a Government physician on or after December 28, 2000, as indicated below. (Check appropriate box below) At least 6 but less than 8 years service (75% of PCA included as basic pay) Less than 2 years service (0% of PCA included as basic pay) At least 2 but less than 4 years service (25% of PCA included as basic pay) At least 8 years service (100% of PCA included as basic pay) At least 4 but less than 6 years service (50% of PCA included as basic pay) 7. Summary of Pay Adjustments with Physicians Comparability Allowance on or after December 28, 2000 A Effective Date of Pay Change B PCA Amount x x x x x x x x x x C % = = = = = = = = = = D Creditable PCA + E Basic Pay Rate = = = = = = = = = = F Average Salary Pay Rate $0 $0 $0 $0 $0 $0 $0 $0 $0 + + + + + + + + + $0 $0 $0 $0 $0 $0 $0 $0 $0 8. Agency Certification: I certify that the information on this form accurately reflects information contained in the Official Personnel Folder and/or Payroll records in the custody of this agency. Print or type name Agency name and address Signature Date Title and telephone number (including area code) This form may be locally reproduced RI 20-122 July 2003 American LegalNet, Inc. www.FormsWorkFlow.com Instructions for entering data into chart: Column A: Enter the effective date for the adjustment in pay. Column B: Enter the entire PCA amount Column C: Enter 100% if separation is due to death-in-service or for disability retirement. Otherwise, the employee is entitled to 25% of the amount in Column B for each two years of service performed as a government physician after December 27, 2000. Enter the following percentages: · · · · · If less than two years, enter 0% If at least two years but less than four years, enter 25% If at least four years but less than six years, enter 50% If at least six years but less than eight years, enter 75% If eight years or more, enter 100% Column D: Enter the amount of creditable PCA pay by multiplying Columns B and C. Column E: Column F: Enter the basic pay rate. Add Columns D and E and enter the amount. This is the amount creditable as average salary. Reverse of RI 20-122 July 2003 American LegalNet, Inc. www.FormsWorkFlow.com