BA-4 (Internet) Report of Creditable compensation Adjustments

Form BA-4: Report of Creditable Compensation Adjustments

Year: __________ Employer BA Number: __________ Social Security Number: ___________________ Increase ( ) or Decrease ( ) Last Name: _____________________ First Name: ___________________ 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:

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Adjusted:

Current Amount

Adjustment Amount

New Amount

Months:

Compensation Amounts Enter only adjustment compensation amounts. New amount values will be calculated automatically.

Current Amount

Adjustment Amount

New Amount

RUIA I:

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. ___________________

Is the adjustment year outside the statute of limitations? If no, skip this section. If yes, select the application reason.

Public Law Board Award:

( )

Settlement Allocation:

( )

Wage Continuation Plan:

( )

RRB Request:

( )

Other Pay for Time Lost Allocation:

( )

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

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(For ERS Forms BA-4 and BA-6a)

Paperwork Reduction Act Notice

We estimate this form takes an average of 20 minutes per response to complete, including the time needed 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 the completion time, to CHIEF OF INFORMATION RESOURCES MANAGEMENT, RAILROAD RETIREMENT BOARD, 844 N. RUSH STREET, CHICAGO, IL 60611-2092.