BA-4 (Internet) Report of Creditable compensation Adjustments

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US Railroad Retirement Board
Form BA-4 (99-99)

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Form Approved
OMB NO. 32204008

Form BA-4: Report Of Creditable Compensation Adjustments
Year:

I

Employer BA Number:

Social Security Number:

Increase ( )

Last Name:

First Name:

or

Decrease ( )

Middle Initial

Service Months
To adjust service months, click the appropriate checkbox in the "Adjusted" row.
Adjustment and New Amount Values will be calculated automatically.
Current:
Adjusted:

q
Jan
q

q
Feb

Mar
q

q
Apr

q
May
0

Current Amount

I

17

Jul
0

q
Aug
0

Adjustment
Amount

q
Sep
0

q
Oct
0

q
Nov
0

17

Dec
0

New Amount

Months:
Compensation Amounts
Enter only adjustment compensation amounts.
New amount values will be calculated automatically.
Current Amount

I

q
Jun
0

.--

Adjustment
Amount

New Amount

RUIA II:
Tier I:
Tier II:
Misc. Comp.:
Sick Pay:

Daily Pay Rate
Enter the full daily pay rate if Form BA-4 is being submitted in lieu of Form BA-3, for the year above.

Public Law Board
Award: ( )

RRB Request:

( 1

Is the adjustment year outside the statute of limitations?
If no, skip this section. If yes, sect the applicable reason.
Settlement
Wage Continuation
Allocation: ( )
Plan: ( )
Other Pay for Time
Lost Allocation:

( )

I

Clear Selection

The information contained in this report is required by law under Section 9 of the Railroad Retirement Act (RRA) and Section 6 of the Railroad
Unemployment Insurance Act (RUIA). By approving this form, I a l r m that to the best of my knowledge, the information I have given is true, complete,
and accurate. I understand that failure to report o r the making of a false o r fraudulent report can result in criminal prosecution o r civil penalties, or both.

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Pa~erworkReduction Act Notice

Display of Paperwork Reduction Act Notice
(For ERS Forms BA-4 and BA-6a)

PAPERWORK REDUC'rION ACT NOTICE

We estimate this form takes an average of 20 minutes to
complete, 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 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.