INCAPACITATION PAY CHECKLIST
This checklist will ensure MPF’s have the minimum necessary documents and actions taken, prior to sending to HQ AFRC/A1KP for
processing.
Rank/Name_______________________________
Unit_____________ AO: _________________________
___ NOT FIT FOR DUTY (422 ONLY)
_____ DEMONSTRATED LOSS OF CIVILIAN INCOME
Preparation: Pull Finance Report(s)
Check ______ ETS __________HYT/MSD
Type of Request: Circle one Initial 1st extension - 2nd extension
REVIEW AF Form 1971: ENSURE THE APPLICATION IS COMPLETED IN ITS ENTIRETY
1. ___ Section I – Members Name, Grade, SSN, Organization, Duty Telephone, Home Addy completed
2. ___ Section II – Fit/Not Fit for Military Duty, Are Diagnosis, Treating Physician, Address and Telephone Number
3. ___Section III, IV, V – Signature of Commander, SJA and Wing CC with recommendations marked.
Note: If SJA is not there it does not stop the process.
THINGS TO QUALITY CHECK ON THE AF FORM 1971
4. ___Are the starting and ending dates the same as the Certification/Recertification Date in Section II?
5. ___ If not fit for military duty the member must have an AF Form 422/AF Form 469 indicating so.
AFRC IMT 348/DD Form 261:
1. ___ Ensure all signatures are completed on form
2. ___ Ensure this form is marked ILOD or EPTS – Service Aggravated
3. ___ Ensure that the form is completed up to block 8 if it is marked “Forward HQ AFRC LOD Board
Note: if the form has been forwarded to HQ AFRC LOD Board and some time has passed since block 8 inquire on
status to your local SG
AF Form 422/ AF Form 469: All profiles must have an expirations date
1. ___AF Form 422: Must be a 4T
2. ___AF Form 469: Must be code 31/ Code 37
3. ___Expiration date of profile must extend beyond the INCAP request end date on the AF1971
4. ___If member is applying for INCAP based on Loss of Civ Income: Treating physician must complete a statement that
the member can no longer perform his civilian job due to the LOD injury for the Incapacitation period.
Note: Indefinite may be accepted for the initial request only based on fitness for duty.
Statement of Earned Income:
1. ___ Does the members letter include the inclusive dates for the Incapacitation pay.
2. ___ Did the member sign and date with a witness signature.
Statement of Employment:
1. ___IF EMPLOYED: Employer must certify gross earnings for dates of incapacitation period on professional employers
letterhead certified by a company figurehead or human resources office. (Letters from supervisors will not be
accepted)
2. The statement must include the amount the member would have earned during incapacitation period and the amount
the member actually earned during incapacitation period. Statement must also indicate if the member received any
income from sick leave or income from any protection plan must be included.
3. _____ SELF-EMPLOYED: Provide a signed statement stating monthly gross income earned before becoming
incapacitated. Copy of profit/loss statement for past 6 months prior to incapacitation, and a copy of bank statements
for past 3 months.
Training Status at the Time of Injury:
1. ___ AF Form 40a, Authorization for Individual Inactive Duty Training (if applicable) or AF Form 938, Request and
Authorization for Active Duty Training/Active duty tour (if applicable)
2. ___Check to ensure that the Date of Injury is equal to the Term of Training
Briefings:
____ Did the member sign a Personnel Briefing, Financial Entitlements Briefing and Signed Medical Briefing