BA-4 (proposed) Report of Creditable Compensation Adjustments

'PropV~E:0

uNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

FORM APPROVED
OMS NO. 3220-0008

REPORT OF CREDITABLE COMPENSATION ADJUSTMENTS
(SEE INSTRUCTlONS FOR COMPLETlNG AND MAiUNG THIS FORM ON REVERSE. SIDE)

The ["fonnallon contained in Illis report, which Is required by law under Section 9 of tile Railroad Retirement Act (RRA) and Section 6 of the Railroad Unemploymenllnsurance Ad (RUIA), Is needed 10 adjusl compensation and service creditable under the RRA and
RUIA. Failure 10 report or Ille making of a false or fraudulent report can resuH In criminal prosecution or civil penalties, or boill.
FORM 0-440 REPORT SPECIFICATIONS SHEET MUST ACCOMPANY THIS FORM.
1. MONTHIYEAR SUBMIITEO
EMPLOYER SA NO.
/3. PAGE NO.

12.

4a. CORPORATE NAME OF EMPLOYER

6.

5.
YEAR

ForRRB

7.
EMPLOYEE
SOCIAL
SECURITY
NUMBER

>

4b. OTHER NAME, IF ANY

EMPLOYEE
NAME
(Last Name;
First MlIm; and
Middle Initial)
3().65

21·29

USeOnlv 2.!i

8.
ADJUST
TYPE
I" Incr
D=Decr
-----­

9.

RUIA COMPENSATION

a.
CREDITABLE
AMT.ADJ.

b'MAXIMUM
BENEFIT
AMT.ADJ.

66-72

10.
J

A

11.

MONTHS ADJUSTED
F
E

M
A

N B R

75·81

(1)

I

slUill

P A
U E C 0
A
M JU JU A
R

Y

N

l

G

P

T

V

E
C

-------­

12:

ADJ~

13.
LAST
DAILY
PAY
RATE

135-1,42

118·122

RRA COMPENSATION

TOTAL a.
SM
ADJ.

b.
TIER I
ADJ.

TIER II
AOJ.

c.
MISCEl.LANEOUS
ADJ.

d.
.SICKPAY

-----

84-95
---c--­
,-------­

--­

-

9$.97

9fl.l05

10fl.115

125-132

(2)
(3)
(4)

m

I

-----­

(6)
(7)

f-

(8)

-----­

r­

(9)

(10j­

-­

(11)
----­

(12)

--­

-­

----­

--­

(13)

0

(14)
-------­

<---~

(15)

14. Recon:!
Count

I

I

15. Enter tile compensation total amounts below. Include a decimal poInt and two digits representing cents ($$$$$$. ~ Enclose negative total amounts in pa_rentheses 10000.00. j'<.
12b RRA Tier II Adj.
12C RRA Miscellaneous Adj.
98t\RUIA Crednable Aml Adj.
RUIA Maximum Benefrt Am\. Adj.
12a.A.RRA TIer (Adj.
A
ll

19b/\.

111174t.­

TiJ17'k...­

'f1li1I-L.

'> t-C6
1·1~RASlckpayAdj.

'Tbl7h-­

f/1!14L..

16. ADJUSTMENT OUTSIDE OF THE STATUTE OF UMITATIONS
PUI>Iic Law Board Award

Hl(~M.

~

Specify Type:

-

Ranroad Retirement Board Request

Wage Coolinuation Plan

SeHiement Allocation

01her Pay for TIme lost Attoeatlon

Other

-­

Spedfy Type:

-

..

~

-~.

,

p0'
INSTRUCTIONS
Thls'report, along with Form <3-440. Reood ~;'catiOns Sheet. is due by the last day of the month immediately following the calendar quarter in which the adjustment occurred or was determined.

'

.

~;~tt('

Mail the forms to the RAILROAD
EMENT
BOARD, OFFICE OF PROGRAAfS. ~rCOMPENSATION AND EMPLOYER SERVICES 'CENTER, 844 NORTH RUSH STREET, CHICAGO, ILUNOIS 60611-2092. Form SA-4 is used to correct creditable service montng, d RUIA
Compensation as well ,as all RRA Compensation (Tier I. TIer II. Miscellaneous and. Sick Pay) previously reported on or omitted from Form SA-3. Annual Report of Creditable Compensation (or obsolete Forms BA-3a, BA-3d. or BA-1 0). \
dilional
informatlon about reporting .creditable compensation adjustments on this form may be found in the "Employer Reporting Instructions."
,
_
UST ALL ITEMS THAT INCLUDE MISCELLANEOUS COMPENSATION OR SICK PAY SEPARA TELY FROM OTHER ITEMS.

Hem
-1-, Enter the month and four-digit yearforwhich the report is submitted, This entry does not refer to the date of the month(s) being adjusted by the Form BA-4.
2. Enter thIi' four-digit Railroad Retirement Board (RRB) employer number. Do not enter the Internal Revenue Service employer Identification number,
3. Number each page IlUbmltted within a calendar month. Including adjustment reports submitted at the request of the RRB.
4. a. Enter the corporate name of the employer.
b. Enter other name. if any. commonly used for business purposes.
5. Enter the four digits of the year being adjusted.
6. Enter the employee's social security number.
7. Enter the employee's last name (up to 20 letters). first name (up to 15 letters). and middle initial.
8. Enter the appropriate code to indicate the type of adjustment.
• I = Increase - if the adjustment is an increase 10 service or compensation previously reported for the employee for the year entered in Item 5 or

the adjustment is an inItial report. fur the year entered in Item 5. for an employee who was omitted from Form SA-3 (or obsolete Form SA-3a) Annual Report of Creditable Compensation.

• 0 .. Decrease.,. If the adjustment is a decrease to service or compensation previously reported for the employee for the year entered in Item 5.
9. a. Enter the net Increase or decrease amountfor the compensation creditable under the RUIA.
b. Enter the net Increase or decrease amount for the total maximum benefit compensation under the RUIA.

Include a decimal point and two digits representing cents ($$$$$$.¢¢).
.

NOTE: See the "Employer Reporting Instrodions· for details on creditability for these two amounts.

10. Enter a "1" In the appropriate toIumn for each month to be adjusted (added or removed) for the year.
11. Enter the total number of months adjusted; this amount should equal the total number of months from Item 10 with a "1."
12. a. Enter the net Increase or decrease amount for regular creditable RRA TIer I compensation.
b. Enter the net Increase or decrease amount for creditable RRA TIer II compensation.

c., Enter the net Increase or decrease amount for miscellaneous RRA compensation.

d. Enter the net Increase or,decrease amount for sick pay RRA compensation.

Include a decimal point and two dlglts representing cents ($$$$$$.¢¢).

13. For employees who were omitted from the annual Fonn BA-3: _ 40. r'l'\ O.f( \,l Y1 ((.e. rlt IV E

Enter the employee's last dally pay rate (DPR). exclus!;l'e of overtime and other allowances. Include a decimal point aild two digits representing cents ($$$.¢¢). Do not enter an amount greater than 200.00.

if the actual DPR is $200.00 or more use a rate of 200.00; if the DPR is less than $200.00 use the actual rate. Compute the last DPR for employees paid on an hourly. monthly, or annual basis as follows:

• Hourly - Multiply the hourly rate by 8.• Monthly - Divide the monthly rate by 21.75.• Annual - Divide the annual rale by months employed, then divide the quotient by 21.75.
Do not use this form to change a previously reported daily pay rate.
SUMMARY ITEMS·
14. Enter the total number of lines which are completed on the page.
15. Summarize the total ilcrease and decrease compensation amounts entered in each column of Items 9(a). 9(b) and 12(a) through 1~ld). Enclose negative total amounts in parentheses.
STATUTEOFLIMITAnON TEMS
:;") S~ 1h"T7T<-(1r;;;i!J
.
16. There is a four-year statute of limitalions for adjusting a report of credilabl~pensation. If the calendar year being adjusted is prior to four years from the current reporting year. indicate the reason the employee's record is being adjusted by

entering the number of the line being. adjusted to the right of the reason. ,or example. for an adjustment fur 1987 on Line 1 because the employee receivad a public law board award. complete the entry as follows: Public Law Board Award _1.

tf more than one employee needs the same adjustmenl, for example, on Unes 1 and 5. complete the entry as follows: Public Law Board Award 1. 5
.
.

Include on the Form (3-440 a summary of each page of Form BM record counts and compensation totals submHted during the current month. Compile the summaries into a grand total.
We estimate this furm takes an average of 75 minutes per response. Including the lime 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 OMS number. If you wish. send comments regarding the accuracy of our estimate or any other aspect of this form. including suggestions fur reducing completion time. to
CHIEF OF INFORMATION RESOURCES MANAGEMENT. RAILROAD RETIREMENT SOARD. 844 N RUSH STREET, CHICAGO. IL 60611·2092.
FormBA-4 (01-08)