G-440 (01-08) Report Specification Sheet

Fonn Approved
OMB No. 3220-0008

UNITED STATES OF AMERICA
RAILROAD RETIREMENT

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

1 CORPORATE NAME AND ADDRESS OF EMPLOYER

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

5

PERSON TO CONTACT REGARDING THIS REPORT

6 TITLE
2 OTHER EMPLOYER NAME. IF ANY

7 TELEPHONE NUMBER

8 FACSIMILE NUMBER

9 E-MAil ADDRESS

10

o

I AM NOT SUBMITTING AN ANNUAL REPORT BECAUSE MY COMPANY HAS NO EMPLOYEES ~ (Go to Item 14, Certification Statement)

O

I AM NOT SUBMITTING A GROSS EARNINGS REPORT BECAUSE MY COMPANY HAS NO EMPLOYEES WITH A SOCIAL SECURITY
NUMBER ENDING IN "30."

11

TYPE OF REPORT (CHECK ONLY ONE)

D

ANNUAL REPORT (FORM BA-3); REPORT INCLUDES:

(Check ALL that apply)
Regular Compensation and Service
Sick Pay and Miscellaneous Compensation
Employee Addresses

D

o

o

o

ADJUSTMENT REPORT (FORM BA-4); REPORT INCLUDES:
(Check ALL that apply)
Regular Compensation and Service
Sick Pay and Miscellaneous

REPORT MEDIUM (CHECK ONLY ONE)

D
D

D
D

SECURE E-MAIL

=

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

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

FTP (File Transfer Protocol) INTERCHANGE

NOTE: Report Record Lengths:
Form BA-3 300 Form BA-4 = 200
Form BA-SA = 180 Form BA-9 = 120
Form BA-11 = 120

D

GROSS EARNINGS REPORT (FORM BA-11)
ADDRESS REPORT (FORM BA-6A)

CD-ROM or 3%" DISKETTE

~------------------------------,

o

D
o
D

MAGNETIC TAPE CARTRIDGE

0

PAPER - Go to Item 13.

D NONE D STANDARD IBM D NON-STANDARD HEADERfTRAILER D LEADING TAPE MARK

(8) FILE NAME:

13 IF YOUR COMPANY IS REPORTING FOR A SUBSIDIARY COMPANY(S). LIST ALL EMPLOYER NUMBERS. ATTACH A SEPARATE SHEET IF NECESSARY.

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
Insurance Act. I certi that to the best of m knowied e the information which I have iven is true com lete and correct.
SIGNATURE OF CERTIFYING OFFICER/DATE

REMARKS

Form G-440 (01-08)

Page _ _ _ of _ __

RECAPITULATION SHEET
NOTE: If more than 1S pages per report photocopy this page before using.

Recapitulation Sheet Instructions
Item 1. Check only one box per report.
Item 2. Report Page # - Enter the page number shown in Item 4 on Form BA-3 or Item 3 on Form BA-4 that you are recapping. NOTE: 1S pages from one report can be recapped
on a single Recapitulation Sheet.
Item 3. Report Record Count - Enter the total number of lines shown in Item 13 on Form BA-3 or Item 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). "
Item 4. Net Compensation Totals - Enter the totals shown in Item 14 on Form BA-3 or Item 15 on Form BA-4 for each page you are recapping.
Item 5. Recap Sheet Page Totals - Summarize the record counts from Item 3 and the compensation amounts from Item 4a-f of this sheet and enter the totals in the respective
columns.
Item 6. Recap Sheet Grand Totals - Single page recapitulation sheet Enter the totals from Item 5, below.
IVIUllI-PClYI:! II:!(;ClPllUIClllun ::.nl:!l:!l- ':)UIIIIIIClIILI:! 1l1:!11I 0 IIUIII I:'d(;11 ::'lIl:'l:'l dliU lIll:'lI I:'lIll:!l ::'UIII lUldl.

D

1. Check One: [ ] Form BA·3, Annual Report
Form BA-4, Adjustment Report
2.
3.
4. NET COMPENSATION TOTALS
RUIA COMPENSATION
REPORT
REPORT
b.
c.
RECORD a.
PAGE
QUALIFYING
MAXIMUM BENEFIT
#
COUNT
AMOUNT
AMOUNT

RRA COMPENSATION

e.

d.

TIERI

TIER II

MISCELLANEOUS
COMPENSATION

f.

SICK PAY

1)

2)
3}

4)

5)
6)
[7)

8}

9)
10)

11)
12)
13)
14)
15)

5. Recap Sheet
Page Totals

0

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

6. Recap Sheet

... Grand Totals
.. .

-­

-

..

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,
for reducing completion time, to CHIEF OF INFORMATION RESOURCES MANAGEMENT, RAILROAD RETIREMENT BOARD, 844 N. RUSH STREET, CHICAGO, IL 60611·2092.

Form G-440 (01-08)

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