Form BA-9 (07-03) BA-9 (07-03) Report of Separation Allowance or Severance Pay

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

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FORM APPRovEn
OMB NO. 3220-0173

REPORT OF SEPARATION ALLOWANCE OR SEVERANCE PAY
(SEE INSTRUCTIONS FOR COMPLETING AND MAILING THlS FORM ON REVERSE SIDE)

The information contained in this report, which is required by law under Section 9 of the Railroad Retirement Act (RRA) and Section 6 of the Railroad Unemployment Insurance
Act (RUIA), is needed for two purposes: to establish eligibility for an additional lump-sum amount under the RRA and to establish a disqualification period under the RUIA.
Failure to report or the making of a false or fraudulent report can result in criminal prosecution or civil penalties, or both.

FORM G-440, REPORT SPECIFICATIONS SHEET, MUST ACCOMPANY THlS FORM.
l a . CORPORATE NAME OF EMPLOYER

1 b. OTHER NAME(S), IF ANY

2. EMPLOYER BA NO. TIP 5-8