BA-11 (proposed) Report of Gross Earnings

FORM APROVED
OMB NO. 3220-xxxx

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

1. YEAR

REPORT OF GROSS EARNINGS

2. EMPLOYER BA NO.

4. TYPE OF REPORT

3. PAGE NUMBER

(Monthly, Quarterly or
Annual Breakdown)

(SEE INSTRUCTIONS FOR COMPLETING AND MAILING THIS FORM ON REVERSE SIDE)

'The purpose of this report is to obtain the gross earnings for a sample of employees. This information
is an integral part of the data needed to compute taxes owed for the Financial Interchange with the
Social Security Administration and the Centers for Medicare & Medicaid Services, and to estimate 5a. NAME OF EMPLOYER
future tax income. The report is required by law (section 209.13 of the Railroad Retirement Board's
Regulations). Failure to report or the making of a false or fraudulent report can result in criminal
I Sb. OTHER NAME, IF ANY
prosecution or civil penalties, or both.

1

FORM G-440, REPORT SPECIFICATIONS SHEET, MUST ACCOMPANY THlS FORM.

I

GROSS EARNINGS AMOUNTS
8 (d)
8(e)
8(0

6.

7.

8(a)

8(b)

8(c)

EMPLOYEE
SOCIAL
SECURITY
NUMBER

EMPLOYEE
NAME
(Last Name,
First Name; and
Middle In~tial)

ANNUAL
1ST
QUARTER

2ND
QUARTER

3RD
QUARTER

4TH
QUARTER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

M-55

56-64

65-73

74-82

83-91

92-100

ForRRB
Use Only

> 11-19

8(g)

8(h)

8(i)

80')

8(k)

8 (1)

JUNE

JULY

AUGUST

SEPTEMBER

OCTOBER

NOVEMBER

DECEMBER

101-109

56-64

65-73

74-82

83-91

92-100

101-109

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Form BA-I 1 (Not Approved For Use)

INSTRUCTIONS
This report, along with Form G-440, Report Specifications Sheet, is submitted annually. File this form no later than the last day of February in the year following the period for which compensation is being
reported. Mail the forms to the RAILROAD RETIREMENT BOARD, BUREAU OF THE ACTUARY, 844 NORTH RUSH STREET, CHICAGO, ILLINOIS 6061 1-2092. Form BA-11 is not required if you have
no employees with social security numbers ending with the digits "30." Instead, check the appropriate box on the Form G-440 submitted with your Form BA-3, Annual Report of Creditable Compensation.
Additional information about reporting gross earnings on this form may be found in the "Employer Reporting Instructions."
Gross earnings consist of all earnings taxable under the hospital insurance portion of the Tier I tax rate, including earnings above the annual creditable limit, sick pay, and miscellaneous compensation.
Item
1.

Enter the four-digit year covered by the report.

2.

Enter the four-digit employer number assigned by the Railroad Retirement Board. Do not enter the Internal Revenue Service employer identification number.

3.

Enter the page number. If there is more than one page, number each page consecutively.

4.

Enter the appropriate type of report (monthly, quarterly, or annual breakdown).
Employers with 5,000 or more employees on their payroll during the year are required to provide a monthly or quarterly breakdown of the year's earnings.
Employers with fewer than 5,000 employees may submit only an annual amount, although a monthly or quarterly breakdown is preferable.

5.

a. Enter the corporate name of the employer.
b. Enter other name, if any, commonly used for business purposes.

6.

Enter the employee's social security number. Report only those employees whose social security number ends with the digits "30."

7.

Enter the employee's last name (up to 20 letters), first name (up to 15 letters), and middle initial.

8.

Enter either monthly, quarterly, or annual gross earning amounts under the appropriate column(s) for each employee. Include a decimal point and two digits representing cents ($$$$$$$.$$).
Column 8(a) Use when reporting annual amounts.
Columns 8(a) through 8(d) - Use when reporting quarterly amounts.
Columns 8(a) through 8(1) - Use when reporting monthly amounts.

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Form BA-I I (Not Approved For Use)