BA-6a (proposed) BA-6a, BA-6 Address Report

FORM APPROVED
OMB NO. 3220-xxxx

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

FORM BA-6 ADDRESS REPORT
(SEE INSTRUCTIONS FOR COMPLETING AND MAILING THIS FORM ON REVERSE SIDE)

The information specified on this form, which is required by law under Section 7(b)(6) of the Railroad Retirement Act and Section 209.1 2 of the Code of Federal Regulations, will be used by the Railroad Retirement
Board to mail Forms BA-6, Certificate of Service Months and Compensation, to the employees of your company. Failure to report or the making of a false or fraudulent report can result in criminal prosecution or
I civil penalties, or both.
FORM G440, REPORT SPECIFICATIONS SHEET, MUST ACCOMPANY THIS FORM.

4.

3.
Social
Security
Number
3ForRRB

.

thoniy PI-g

EMPLOYEE
NAME
(Last Name;
First Name; and
Middle Initial)
i045

Form BA-6a (Not Approved For Use)

2. EMPLOYER BA NO.

Ib. OTHER NAME, IF ANY

l a . CORPORATE NAME OF EMPLOYER

5a.

5b.

8.

7.

6.

Street Address
Line 1

Street Address
Line 2

City

46.75

76105

16125

9.

State

ZIP
Code

Effective
Date

126-123

178132

14,+1<52

.

\

INSTRUCTIONS
The information requested on this report, along with Form G-440, Report Specifications Sheet, is to be submitted annually, no later than April 1 of the year following the reportable
calendar year. Note: In lieu of this form, the employer may include the information on Form BA-3, Annual Report of Creditable Compensation, if that report is submitted as an
automated file. Mail the report to the RAILROAD RETIREMENT BOARD, OFFICE OF PROGRAMS, A&T- COMPENSATION AND EMPLOYER SERVICES CENTER, 844 NORTH RUSH STREET,
CHICAGO, ILLINOIS 60611-2092. No report is required if the employer has previously furnished home address information for all persons employed in the reportable calendar year.
Address information is required only for employees for whom the employer has not previously furnished address information. Additional information about reporting addresses on this
form may be found in the "Employer Reporting Instructions."

1. a. Enter the corporate name of the employer.
b. Enter other name, if any, commonly used for business purposes.
2. Enter the four-digit BA number which is assigned to the employer by the Railroad Retirement Board.
3. Enter the employee's social security number.
4. Enter the employee's last name (up to 20 letters), first name (up to 15 letters), and middle initial.

5. a. Enter the first line of the employee's street address. This line should not exceed 30 characters, including spaces.
b. Enter the second line of the employee's street address, if needed. This line should not exceed 30 characters, including spaces.
6. Enter the name of the city. The city's name should not exceed 20 characters.

7. Enter the two-letter abbreviation of the state.
8. Enter the five-digit ZIP code.

9. Enter the effective date of the change of address in the eight-digit format MMDDYYYY. This date should reflect the date the employer recorded the address in their files. If the
employer cannot determine the date, this item should be left blank.
We estimate this form takes an average of 32 minutes per response, including the 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 aspect of this form, including suggestions for reducing completion time, to CHIEF OF INFORMATION RESOURCES
MANAGEMENT, RAILROAD RETIREMENT BOARD, 844 N RUSH STREET, CHICAGO, IL 60611-2092.

Form BA-6a (Not Approved For Use)