G-440 (proposed)

FORM APPROVED
O M . NO. 3220-XXXX

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

REPORT SPECIFICA'I'IONS SHEET

\

RETURN TO:
(Address on reverse side of reporting form)
U.S. RAILROAD RETIREMENT BOARD
844 NORTH RUSH STREET
CHICAGO, IL 60611-2092

IMPORTANT NOTE:
This form must be completed and submitted with reports of
information required by law under Section 9 of the Railroad
Retirement act (RRA) and Section 6 of the Railroad
Unemployment Insurance Act (RUIA) for the purpose of paying
RRA and RUIA benefits.
3 DATE REPORT BEING SUBMITTED 4 EMPLOYER BA NUMBER

1 CORPORATE NAME AND ADDRESS OF EMPLOYER

5 PERSONTO CONTACT REGARDING THIS REPORT

I

6 TITLE

2 OTHER EMPLOYER NAME, IFANY

I

1 7 TELEPHONE NUMBER

I

8 FACSIMILE NUMBER

I
IAM NOT SUBMllTlNG AN ANNUAL REPORT BECAUSE MY COMPANY HAS NO EMPLOYEES

b (Go to Certification Statement at bottom)

IAM NOT SUBMrrrlNG A GROSS EARNINGS REPORT BECAUSE MY COMPANY HAS NO EMPLOYEES WITH A SOCIAL SECURITY
NUMBER ENDING IN 10."

11 REPORT MEDIUM (CHECK ONLY ONE)

10 TYPE OF REPORT (CHECK ONLY ONE)

MAGNETIC TAPE CARTRIDGE

ANNUAL REPORT (FORM BA-3); REPORT INCLUDES:
(Check ALL that apply)
Regular Compensation and Service
Sick Pay and MiscellaneousCompensation
Employee Addresses
ADJUSTMENT REPORT (FORM BA-4); REPORT INCLUDES:
(Check ALL fhat apply)
Regular Compensation and Service
Sick Pay and Miscellaneous

CD-ROM or 3%- DISKElTE
FTP (File Transfer Protocol) INTERCHANGE

.

SECURE E-MAIL
>

NOTE: Report Record Lengths:
Form BA-3 = 300 Form BA-4 = 200
Form BA-6A = 180 Form BA-9 = 120

SEPARATIONALLOWANCUSNERANCE PAY REPORT (FORM BA-9)
GROSS EARNINGS REPORT (FORM BA-1I)

-

PAPER Go t~ Item 13.

ADDRESS REPORT (FORM BA-GA)

12 (A) LABEL USED (CHECK ONLY ONE):

NONE

STANDARD IBM

NONSTANDARD HEADEMRAILER

LEADINGTAPE MARK

(6) FILE NAME:
(C) REEL NUMBER(S)

c.

13 IF YOUR COMPANY IS REPORTING FOR A SUBSlDlARY COMPANY(S), LIST ALL EMPLOYER NUMBERS. AlTACH A SEPARATE SHEET IF NECESSARY.

I

I
14 I understand that civil and criminal penalties can be imposed against me for false or fraudulent statements or for withholding information
to misrepresent a fact material to determining a right to payment under the Railroad Retirement Act or the Railroad Unemployment
InsuranceAct. I certify that, to the best of my knowledge, the informationwhich Ihave given is true, complete, and correct.
SIGNATURE OF CERTIFYING OFFICERIDATE

REMARKS

Fonn G-440 (Not Approved For Use

Page

of

RECAPITULATION SHEET
NOTE: I f more than 15 pages per report, photocopy this page before using.
Recapitulation Sheet Instructions
ltem 1. Check only one box per report.
ltem 2. Report Page # Enter the page number shown in ltem 4 on Form BA-3 or ltem 3 on Form BA-4 that you are recapping. NOTE: 15 pages from one report Can be recapped
on a single RecapitulationSheet.
ltem 3. Report Record Count Enter the total number of lines shown in ltem 13 on Form BA-3 or ltem 14 on Form BA-4 for each page YOU are recapping.
NOTE: For Items 4, 5, and 6, below, enclose negative amounts in parentheses, i.e., "(10,000.00)".
ltem 4. Net Compensation Totals Enter the totals shown in Item 14 on Form BA-3 or ltem 15 on Form BA-4 for each page you are recapping.
ltem 5. Recap Sheet Page Totals Summarize the record counts from Item 3 and the compensation amounts from ltem 4a-f of this sheet and enter the totals in the respective
columns.
ltem 6. Recap Sheet Grand Totals Single page recapitulationsheet Enter the totals from ltem 5, below.
Multi-page recapitulation sheet Summarize ltem 5 from each sheet and then enter sum total.
Form BA-4, Adjustment Report
Form BA-3, Annual Report
1. Check One:
4. NET COMPENSATION TOTALS
2.
3.
RRA COMPENSATION
RUlA COMPENSATION
REPORT
REPORT
f.
e.
d.
C.
b.
PAGE
RECORD a.
MISCELLANEOUS
QUALIFYING
MA)(lMUMBENEFIT
SICK PAY
TIER II
TIER I
#
COUNT
COMPENSATION
AMOUNT
AMOUNT

-

-

-

-

--

3)

\ tzda

ii

t"3'

6
* I .

:

'I

*

i4)

5)

:

P
'

[B)

fYa

2

C

2p,

L
'

3)
To)
31)

3)

m)
14)

r3-5)

5. Recap Sheet

I

Page Totals

6. Recap Sheet
Grand Totals
We estimate this form takes from I 5 to 75 minutes per response, including the time for reviewing instructions. getting the needed data
and reviewing the completed farm. Federal agencies may not
or sponsors and respondents
are not required to respond to a collection Of lnformatlon
unless ItdlSPla~
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 to
OF INFORMATION RESOURCES MANAGEMENT, RAILROAD RETIREMENT BOARD, 844 N. RUSH STREET, CHICAGO, IL 60611-2092.

Form (3-440 (Not Approved For Use)