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{"sheet":"Instructions","index":0,"n_rows":13,"n_cols":2,"rows_kept":13,"cut":false,"hidden":false,"merged":[[0,0,0,8],[12,1,12,8],[3,0,3,8],[6,1,6,8],[8,1,8,8],[10,1,10,8],[1,0,1,8]]}
[]
["Request for A One-Time Unpaid Benefit Premium Adjustment"]
["Instructions"]
["Use this form to request additional one-time deductions for State of Arizona employees to ensure that unpaid benefit premiums reflect the amount owed by the employee and employer for benefits coverage. \nThe One-Time Unpaid Benefit Premium Adjustment form is used to refund employer deductions that should be paid by the employee and add an employee charge for the amount owed.\n\nThe GAO – 73B should be used in circumstances where an employee owes the employer share of benefit premiums. The GAO – 73B will have two lines per employee for each benefit coverage period. The first line will be a negative deduction amount for the applicable employer premium deduction code. The negative indicates a refund is due. The second line will be a positive deduction amount for a post-tax charge to the employee for employer share of the benefit premium. Deduction codes to use, if applicable, are D181 and D187 for Dental and M183 and M187 for Medical.\n\nThe grey fields are linked to the ER deduction, Employee Amount, and PPE entered data. Do not manually enter data in the gray fields.\n\nOnce completed, email Central.Payroll@azdoa.gov by the appropriate deadline:\n• Payday: by 12:00 p.m. (noon) compute Tuesday\n• Daily Handwrite: by 12:00 p.m. (noon) daily\n• For Biweekly Billing Statement: by 12:00 p.m. (noon) on pay week Friday"]
[]
["Key Terms"]
["Deduction Code:","Select the deduction code from the Deduction Code and Description drop down list. Select the employer (ER) deduction. The ER selection will autopopulate the employee (EE) deduction. Ensure this is the correct deduction that should be used."]
[]
["Deduction Amount:","A positive amount indicates a deduction and negative amount indicates a refund. Enter the employee deduction amount (positive/charge amount). The employer deduction amount (negative/refund amount) will auto populate."]
[]
["Under 30 Hour Report Pay Period:","Select the Pay Period End Date (PPE) from the Under 30 Hour Report located in the Data Warehouse in the Agency Benefits Reports folder. The One-Time Deduction Date (OTD) – the prior pay date – for the benefits coverage period will populate based on the PPE. Ensure the OTD is both correct and a pay date or the form will be returned for corrections and resubmission."]
[]
["Comment:","Enter any comments that pertain to the deduction that might be helpful for validating the deduction amount."]

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[]
["Request for A One-Time Unpaid Benefit Premium Adjustment"]
[]
["Agency"]
[]
[null,"Employee Name","EIN","Deduction Code and Description",null,null,null,null,"Deduction Amount","Under 30 Hour Report"]
[1,null,null,"ER","Select ER Deduction",null,null,null,{"$f":"I8*-1","v":0},"PPE"]
[null,null,null,"EE",{"$f":"VLOOKUP(E7,'DEDUCTION CODE SELECTION'!A1:B13,2,0)","v":"EE Deduction"},null,null,null,null,"OTD",{"$f":"K7-8","v":-8}]
[null,null,null,"Comment"]
[2,null,null,"ER","Select ER Deduction",null,null,null,{"$f":"I11*-1","v":0},"PPE"]
[null,null,null,"EE",{"$f":"VLOOKUP(E10,'DEDUCTION CODE SELECTION'!A1:B13,2,0)","v":"EE Deduction"},null,null,null,0,"OTD",{"$f":"K10-8","v":-8}]
[null,null,null,"Comment"]
[3,null,null,"ER","Select ER Deduction",null,null,null,{"$f":"I14*-1","v":0},"PPE"]
[null,null,null,"EE",{"$f":"VLOOKUP(E13,'DEDUCTION CODE SELECTION'!A1:B13,2,0)","v":"EE Deduction"},null,null,null,0,"OTD",{"$f":"K13-8","v":-8}]
[null,null,null,"Comment"]
[4,null,null,"ER","Select ER Deduction",null,null,null,{"$f":"I17*-1","v":0},"PPE"]
[null,null,null,"EE",{"$f":"VLOOKUP(E16,'DEDUCTION CODE SELECTION'!A1:B13,2,0)","v":"EE Deduction"},null,null,null,0,"OTD",{"$f":"K16-8","v":-8}]
[null,null,null,"Comment"]
[5,null,null,"ER","Select ER Deduction",null,null,null,{"$f":"I20*-1","v":0},"PPE"]
[null,null,null,"EE",{"$f":"VLOOKUP(E19,'DEDUCTION CODE SELECTION'!A1:B13,2,0)","v":"EE Deduction"},null,null,null,0,"OTD",{"$f":"K19-8","v":-8}]
[null,null,null,"Comment"]
[6,null,null,"ER","Select ER Deduction",null,null,null,{"$f":"I23*-1","v":0},"PPE"]
[null,null,null,"EE",{"$f":"VLOOKUP(E22,'DEDUCTION CODE SELECTION'!A1:B13,2,0)","v":"EE Deduction"},null,null,null,0,"OTD",{"$f":"K22-8","v":-8}]
[null,null,null,"Comment"]
[7,null,null,"ER","Select ER Deduction",null,null,null,{"$f":"I26*-1","v":0},"PPE"]
[null,null,null,"EE",{"$f":"VLOOKUP(E25,'DEDUCTION CODE SELECTION'!A1:B13,2,0)","v":"EE Deduction"},null,null,null,0,"OTD",{"$f":"K25-8","v":-8}]
[null,null,null,"Comment"]
[8,null,null,"ER","Select ER Deduction",null,null,null,{"$f":"I29*-1","v":0},"PPE"]
[null,null,null,"EE",{"$f":"VLOOKUP(E28,'DEDUCTION CODE SELECTION'!A1:B13,2,0)","v":"EE Deduction"},null,null,null,0,"OTD",{"$f":"K28-8","v":-8}]
[null,null,null,"Comment"]
[9,null,null,"ER","Select ER Deduction",null,null,null,{"$f":"I32*-1","v":0},"PPE"]
[null,null,null,"EE",{"$f":"VLOOKUP(E31,'DEDUCTION CODE SELECTION'!A1:B13,2,0)","v":"EE Deduction"},null,null,null,0,"OTD",{"$f":"K31-8","v":-8}]
[null,null,null,"Comment"]
[10,null,null,"ER","Select ER Deduction",null,null,null,{"$f":"I35*-1","v":0},"PPE"]
[null,null,null,"EE",{"$f":"VLOOKUP(E34,'DEDUCTION CODE SELECTION'!A1:B13,2,0)","v":"EE Deduction"},null,null,null,0,"OTD",{"$f":"K34-8","v":-8}]
[null,null,null,"Comment"]
[]
[]
["Prepared by",null,null,null,null,null,"Reviewed by"]
["Name",null,null,null,null,null,"Name"]
["EIN",null,null,null,null,null,"EIN"]
["Phone",null,null,null,null,null,"Phone"]
["Date",null,null,null,null,null,"Date"]

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["PAYDATE","PAY PERIOD BEGIN","PAY PERIOD END","OTD Date"]
[]
["2023-12-14","2023-11-25","2023-12-08","2023-11-30"]
["2023-12-28","2023-12-09","2023-12-22","2023-12-14"]
["2024-01-11","2023-12-23","2024-01-05","2023-12-28"]
["2024-01-25","2024-01-06","2024-01-19","2024-01-11"]
["2024-02-08","2024-01-20","2024-02-02","2024-01-25"]
["2024-02-22","2024-02-03","2024-02-16","2024-02-08"]
["2024-03-07","2024-02-17","2024-03-01","2024-02-22"]
["2024-03-21","2024-03-02","2024-03-15","2024-03-07"]
["2024-04-04","2024-03-16","2024-03-29","2024-03-21"]
["2024-04-18","2024-03-30","2024-04-12","2024-04-04"]
["2024-05-02","2024-04-13","2024-04-26","2024-04-18"]
["2024-05-16","2024-04-27","2024-05-10","2024-05-02"]
["2024-05-30","2024-05-11","2024-05-24","2024-05-16"]
["2024-06-13","2024-05-25","2024-06-07","2024-05-30"]
["2024-06-27","2024-06-08","2024-06-21","2024-06-13"]
["2024-07-11","2024-06-22","2024-07-05","2024-06-27"]
["2024-07-25","2024-07-06","2024-07-19","2024-07-11"]
["2024-08-08","2024-07-20","2024-08-02","2024-07-25"]
["2024-08-22","2024-08-03","2024-08-16","2024-08-08"]
["2024-09-05","2024-08-17","2024-08-30","2024-08-22"]
["2024-09-19","2024-08-31","2024-09-13","2024-09-05"]
["2024-10-03","2024-09-14","2024-09-27","2024-09-19"]
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["2024-10-31","2024-10-12","2024-10-25","2024-10-17"]
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["2024-12-12","2024-11-23","2024-12-06","2024-11-28"]
["2024-12-26","2024-12-07","2024-12-20","2024-12-12"]
["2025-01-09","2024-12-21","2025-01-03","2024-12-26"]
["2025-01-23","2025-01-04","2025-01-17","2025-01-09"]
["2025-02-06","2025-01-18","2025-01-31","2025-01-23"]
["2025-02-20","2025-02-01","2025-02-14","2025-02-06"]
["2025-03-06","2025-02-15","2025-02-28","2025-02-20"]
["2025-03-20","2025-03-01","2025-03-14","2025-03-06"]
["2025-04-03","2025-03-15","2025-03-28","2025-03-20"]
["2025-04-17","2025-03-29","2025-04-11","2025-04-03"]
["2025-05-01","2025-04-12","2025-04-25","2025-04-17"]
["2025-05-15","2025-04-26","2025-05-09","2025-05-01"]
["2025-05-29","2025-05-10","2025-05-23","2025-05-15"]
["2025-06-12","2025-05-24","2025-06-06","2025-05-29"]
["2025-06-26","2025-06-07","2025-06-20","2025-06-12"]
["2025-07-10","2025-06-21","2025-07-04","2025-06-26"]
["2025-07-24","2025-07-05","2025-07-18","2025-07-10"]
["2025-08-07","2025-07-19","2025-08-01","2025-07-24"]
["2025-08-21","2025-08-02","2025-08-15","2025-08-07"]
["2025-09-04","2025-08-16","2025-08-29","2025-08-21"]
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["2025-10-02","2025-09-13","2025-09-26","2025-09-18"]
["2025-10-16","2025-09-27","2025-10-10","2025-10-02"]
["2025-10-30","2025-10-11","2025-10-24","2025-10-16"]
["2025-11-13","2025-10-25","2025-11-07","2025-10-30"]
["2025-11-27","2025-11-08","2025-11-21","2025-11-13"]
["2025-12-11","2025-11-22","2025-12-05","2025-11-27"]
["2025-12-25","2025-12-06","2025-12-19","2025-12-11"]

{"sheet":"GUIDELINES","index":3,"n_rows":0,"n_cols":0,"rows_kept":0,"cut":false,"hidden":true,"merged":[]}

{"sheet":"DEDUCTION CODE SELECTION","index":4,"n_rows":13,"n_cols":2,"rows_kept":13,"cut":false,"hidden":true,"merged":[]}
["Select ER Deduction","EE Deduction"]
["DENTAL","DENTAL"]
["D006 - DELTA DENTAL - ER             ","D181 - DENTAL-DELTA-ER PORTION"]
["D012 - UHC DENTAL - ER","D187 - DENTAL-UHC-ER PORTION"]
["MEDICAL","MEDICAL"]
["M032 - BCBSAZ HDHP-ER ","M183 - MEDICAL-BCBS-ER PORTION"]
["M034 - BCBSAZ TRIPLE-ER ","M183 - MEDICAL-BCBS-ER PORTION"]
["M036 - UNITED HEALTH HDHP-ER ","M187 - MEDICAL-UHC-ER PORTION"]
["M038 - UNITED HEALTH TRIPLE-ER ","M187 - MEDICAL-UHC-ER PORTION"]
["M204 - ER HSA BC CONTRIBUTION SINGLE ","M183 - MEDICAL-BCBS-ER PORTION"]
["M206 - ER HSA BC CONTRIBUTION FAMILY ","M183 - MEDICAL-BCBS-ER PORTION"]
["M208 - ER HSA UHC CONTRIBUTION SINGLE","M187 - MEDICAL-UHC-ER PORTION"]
["M210 - ER HSA UHC CONTRIBUTION FAMILY","M187 - MEDICAL-UHC-ER PORTION"]