Form GL-99 (08-03) GL-99 (08-03) Employer's Deemed Service Months Questionnaire

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOAR0

FORM APPROVED
OMB NO. 3220-0 156

EMPLOYER'S DEEMED SERVICE MONTHS QUESTIONNAIRE
BA

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INSTRUCTIONS

The purpose of this form is to obtain information needed to
determine whether the employee identified below can be
credited with additional service months in accordance with
provisions of Section 3(i) of the Railroad Retirement Act (RRA).
Our authority for requesting the information is Section 9 of the
RRA. Reporting is mandatory under the law. Failure to report
or the making of a false or fraudulent report can result in criminal
prosecution or civil penalties, or both.

ALWAYS COMPLETE ITEM 8. Check YES or NO for
each month listed in item 7.
For an explanation of deemed service months and the
completion of this form, see the "Reporting Instructions to
Employers."
If the name, service months, or
compensation is incorrect, correct it and answer the
questions based on the corrected information. Enter an
explanation of the correction, in the remarks.
If
corrections are to service months or compensation, you
must also file Form BA-4, Report of Creditable
Compensation Adjustments. Please attach the form BA4 to this questionnaire or give date filed. Do not change
the year in item 4. Mail the completed form to:

We estimate this form takes an average of 2 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 aspects of
this form including suggestions for reducing completion time, to
Chief of Information Resources Management, Railroad
Retirement Board, 844 North Rush Street, Chicago, IL 606112092.

U.S. Railroad Retirement Board
Assessment and Training
Compensation and Employer Services Center
844 North Rush Street
Chicago, IL 60611-2092

1
1 2. SOCIAL SECURITY- NUMBER

I. NAME

-

3. PAYROLL NO.

4. YEAR

5.

SERVICE MONTHS REPORTED

6. TIER II COMPENSATION

7. MONTHS NOT WORKED

8.

EMPLOYEE IN. EMPLOYMENT
RELATIONSHIP?

If an employee'was in an employment
relationship-part of a month, check YES.
An employment relationship exists in a
month not worked if the employee was on
furlough. authorized leave of absence, sick
or disability leave, training, etc.
An employment relationship does not exist
f the employee was discharged, resigned.
retired, relinquished his or her job
rights. died. etc. For this purpose, an
employment relationship does not exist if
an employee transferred to a position
determined not to be covered under the
Railroad Retirement A c t

9. REMARKS

FOR
RRB
USE

OBTAXNG

KNOWING THAT ANYONE WHO MAKES A FALSE OR FRAUDULENT STATEMENT FOR THE PURPOSE OF
BENEFITS FROM
THE RRB IS COMMITTING A CRIME PUNISHABLE UNDER FEDERAL LAW. I CERTIFY THAT THE INFORMATION IS TRUE, CORRECT. AND

COMPLETE.

1 SIGNATURE OF CERTIFYING OFFICER

I TITLE OF CERTIFYING OFFICER

'

I

TELEPHONE NUMBER

FACSIMILE NUMBER

DATE

FORM GL-99 (08-03)