BA-9 (proposed) Report of Separation Allowance or Severance Pay

FORM APPROVED
OMB NO. 3220-xxxx

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

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 (RLIIA), 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 4 0 , REPORT SPECIFICATIONS SHEET. MUST ACCOMPANY THlS FORM.
la. CORPORATE NAME OF EMPLOYER

3.

4.

5.

lb. OTHER NAME, IF ANY

6.

7.

Employee
(Last Name;
First Name; and
Middle Initial)

Form BA-9 (Not Approved For Use)

2. EMPLOYER BA NO.

Separation
Allowance or
Severance Pay
Amt Subject to
Tier II Taxation
or Correction to

8.

Code

10.

9.

Date Rights
Relinquished

Amount of Separation
Allowance from Item 7
Included on
Form BA-3 or
Form BA-4 and
Year Reported

12.

II.

Total Gross
Amount of

13.

14.

INSTRUCTIONS
This report, along with
G440, Report Specifications Sheet, is submitted no later than the last day of the month following the end of the quarter in which the separation allowance or severance pay was paid. Mail the forms
to the RAILROAD RETIREMENT BOARD, OFFICE OF PROGRAMS, A&T - COMPENSATION AND EMPLOYER SERVICES CENTER, 844 NORTH RUSH STREET, CHICAGO, ILLINOIS 60611-2092. Additional
information about reporting separation allowances and severance pay on this form may be found in the "Employer Reporting Instructions."
ltem
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1. a. Enter the corporate name of the employer.
b. Enter other name, if any, commonly used for business purposes.
2. Enter the fourdigit Railroad Retirement Board employer number. Do not enter the Internal Revenue Service employer identification number.
3. Enter the applicable fourdigit tax year.
4. Enter a "4" for an initial report or an increase adjustment. Enter an "M" for a decrease adjustment.
5. Enter the employee's social security number.
6. Enter the employee's last name (up to 20 letters), first name (up to 15 letters), and middle initial.
7. For an initial report, enter the amount of separation allowance or severance pay subiect to Tier I1 taxation. For an adjustment report, enter the net increase or decrease amount to be applied to the previous report. If an
allowance or payment is made to an employee who had already been credited with maximum earnings in that year and no tax is deducted, enter 0.00. If a separation allowance or severance pay was paid in more than one
year, the amount subject to Tier II tax in each year should be shown on a separate line. Include a decimal point and two digits representing cents ($$$$$$.$$).
8. Enter a "1" for an initial report or the first periodic payment of the separation allowance. Enter a "2" for an adjustment to a previous report. Enter a "3" for a periodic payment-not the initial or final payment. Enter a "4" for a
periodic payment-final payment. If you enter a "1," ltems 11-14 must be completed.
9. Enter the date the employee separated and relinquished employment rights in the eightdigit format MMDDYYYY. The date the employee separated and relinquished rights remains the same even when the separation
allowance or severance payment was paid in yearly installments.
10. a. Enter the amount of all or part of the separation allowancelseverance payment in ltem 7 that was creditable compensation and included on your Form BA-3 (or obsolete Form BA-3a or BA-3d), Annual Report of
Creditable Compensation, or credited to the date last worked on Form BA-4, Report of Creditable Compensation Adjustments. Include a decimal point and two digits representing cents ($$$$$$.$$). If the amount
is zero, make no entry.
b. Enter the fourdigit year for which the amount from ltem 1Oa was reported. If ltem 1Oa is left blank, this item should be blank also.

OPTIONAL: ltems 11 through 14 are optional unless ltem 8 is marked "1."
11.

Enter in whole dollars the total gross amount of the separation or severance allowance. The amount should be rounded, if necessary, so that it will not include two digits representingcents. This amount is not reduced
for payroll deductions, for either Tier I or Tier II compensation maximums, or tax ceilings. If the amount is being paid in installments, show the sum of all the installments before deductions. If the separation or severance
pay is being paid in installments over several years, complete ltems 11 through 14 only for the first year the installment payments are reported. Show the gross amount of the separation Or severance
payment (i.e., the total of all installment payments that will be made to the employee) in Item 11. Do not complete entries for the other years in which the installmentswere paid.
12. Enter the employee's last rate of pay. This amount is used to establish a disqualification period under the RUIA.
Code 4 - month.
13. Enter the code corresponding to the period to which the rate of pay applies.
Code 2 - day.
Code 1 - hour.
Code 3 - week.
Code 5 - fiveday week.
Code 6 sixday week.
Code 7 - sevenday week.
Code 8 - train and engine service.
Code - dining car and
14. Enter the code corresponding to the employee's normal workweek.
Pullman service.

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We estimate this form takes an average of 76 minutes per response to complete, including time for reviewing the instructions, getting the needed data, and reviewing the completed form. Federal agencies may not conduct or
sponsor, and respondents are not required to respond to, a collection of information unless it displays a valid OMB number. If you wish, send comments regarding the accuracy of our estimate or any other aspects of this form,
including suggestions for reducing completion time to: CHIEF OF INFORMATION RESOLIRCES MANAGEMENT, RAILROAD RETIREMENT BOARD, 844 N RUSH ST, CHICAGO, IL 60611-2092.

Form BA-9 (Not Approved For Use)