G-440 (07-03)

REPORT SPECIFICATIONS 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 ENCLOSED WITH
EACH REPORT SUBMITTED. BE SURE TO COMPLETE THE
RECAPITULATION SHEET ON THE REVERSE SIDE OF THIS
FORM IF SUBMITTING FORMS BA-3A, BA-4, OR BA-10.

DATE REPORT BEING SUBMITTED

EMPLOYER NUMBER (BA NUMBER)

CORPORATE NAME AND ADDRESS OF EMPLOYER

PERSON TO CONTACT REGARDING THIS REPORT

TITLE

OTHER EMPLOYER NAME(S), IF ANY

TELEPHONE NUMBER

FACSIMILE NUMBER

I AM NOT SUBMITTING A REPORT BECAUSE MY COMPANY HAS NO EMPLOYEES  (Go on to Certification Statement at bottom)
REPORT MEDIA
(Check only one)

TYPE OF REPORT
(Check only one)
ADDRESS REPORT (FORM BA-6a)

ANNUAL REPORT (FORM BA-3a)
Form BA-6a not submitted
because no new hires

PAPER

SEPARATION ALLOWANCE/SEVERANCE PAY REPORT
(FORM BA-9)

ANNUAL REPORT WITH
MISCELLANEOUS COMPENSATION
(Magnetic Tape in BA-3d Format)

MISCELLANEOUS COMPENSATION REPORT
(FORM BA-10)

ADJUSTMENT REPORT (FORM BA-4)

GROSS EARNINGS REPORT (FORM BA-11)

3½ DISKETTE
CD ROM
MAGNETIC TAPE/CARTRIDGE
Also complete items (a)-(f) below.

MAGNETIC TAPE AND CARTRIDGE REPORTS ONLY (Items (a) through (f) must be COMPLETED)
(a)

(b)
Tape or Cartridge Labels
Standard IBM Labels

(c)
Tape Density
(Tape Only)
6250 BPI

No Labels
1600 BPI
Non-standard Header and Trailer Labels
Leading Tape Mark Only
(f) Data Set Name (DSN):

Type of
Tape or
Cartridge
3480 type
cartridge
3490 type
cartridge
9 Track Tape

(d)

(e)
Blocking Factor

Reel Numbers

FOR RRB USE
RRB-Reels

Record format must be fixed
blocked. Record size must
be consistent with type of
report indicated above.

How Many Characters
Per Block?

FORMS BA-3A, BA-4, BA-9, BA-10 AND
BA-11 MUST BE IN 80 CHARACTER
FORMAT. THE BA-3D AND FORM BA-6A
MUST BE IN 120 CHARACTER FORMAT.

DATE RECEIVED IN OP-A&T-CESC

ENTER EMPLOYER NUMBERS OF ALL SUBSIDIARY UNITS INCLUDED IN THE REPORT. ATTACH ADDITIONAL SHEET IF NECESSARY.

FOR RRB
USE ONLY

CERTIFICATION STATEMENT
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. I CERTIFY THAT, TO THE BEST OF MY KNOWLEDGE, THE
INFORMATION WHICH I HAVE GIVEN IS TRUE, COMPLETE, AND CORRECT.

SIGNATURE OF CERTIFYING OFFICER/DATE

Form G-440 (03-02) PRIOR EDITIONS ARE OBSOLETE

REMARKS

Page ______ of ______
RECAPITULATION SHEET
(IF MORE THAN 15 PAGES PER REPORT, PHOTOCOPY THIS PAGE BEFORE USING.)
INSTRUCTIONS—1. Check only one box per report. 2. Page # - Enter the page number of the report you are recapping. A maximum of 15 pages of that report can be recapped on a
single recapitulation sheet. 3. Record Count - Enter the total number of lines used on each page of the form you are recapping. 4. Compensation Totals - Enter the compensation totals
that are at the bottom of the form you are recapping. If sick pay, check the sick pay box, etc. 5. Record Totals - Enter the total of all counts entered under Item 3., then show the totals of
each column for the rest of the line. 6. Grand Totals - If more than one page is needed to do your recapitulation, fill in the Grand Totals on the last page of the report.
1. Check Only One Box
2.

3.

Page
#

Record
Count

Form BA-3a (Use Increase columns only)

Form BA-4

4.

RUIA Increase

RUIA Decrease

Form BA-10 (Use Tier I columns to report Sick Pay or Miscellaneous Compensation)
COMPENSATION TOTALS

Tier I Increase

Tier I Decrease

Sick Pay

Misc. Comp.

Tier II Increase

Tier II Decrease

5.

Record
Totals

0

$0.00

6.

Grand
Totals

Form G-440 (03-02) PRIOR EDITIONS ARE OBSOLETE

$0.00

$0.00

$0.00

$0.00

$0.00