BA-12 (proposed) Application for Employer Reporting Internet Access

Form Approved

United States ofAmerica
Railroad Retirement Board

OMB No. 3220-0008

Application for Employer Reporting Internet Access
General Instructions-This form may be used by employers covered under the Railroad Retirement and Railroad
Unemployment Insurance Acts to add, modify, or terminate employee access to the Railroad Retirement Board's (RRB)
Internet Employer Reporting System. You may request system access for one or more employees, and you may
authorize different levels of access for each employee. You may also request that an individual employee file online
reports on behalf of one or more subsidiary or affiliate employers. In each case, your employees must certify that they will
adhere to the RRB's security guidelines, which include the use of an authoritative electronic signature. The Security
Guidelines are on the RRB's web site at www.rrb.gov/AandT/ERI/Part8/ChapterB.asp.
To request new or modified system access, complete the entire form. To terminate an employee's access, complete only
Sections A, B (1-4), C (1), and D.
Making representations on this form to gain unauthorized access to the RRB Employer Reporting System or
using an authorized access for fraudulent purposes is a violation of federal law punishable by fine,
imprisonment, or both.
Section A

Employer Information

In this section, enter the BA number, name, and address of the employer whose reports will be accessed online.
Special Instructions to Request Access on Behalf of Multiple Employers-If you are requesting the ,same level of
access for the employee listed in Section B on behalf of multiple employers, list all affected BA numbers in Item 1. If you
are requesting different levels of access for this employee for different employers, file a separate application for each
level of access.

1. BA Number(s):
2. Name and Address of Employer-If you are requesting access on behalf of multiple employers, provide only the
name and address of the employer serving as primary contact for this account.

Section B

Employee Information

1. Name:
2. Title:

3.

Telephone Number:

4.

E-Mail Address:

(
5. I have read the document "Security Guidelines" and agree to comply with these guidelines. I understand that my
logon, if used to file forms, has the same status as my signature on a paper document. I also understand that
providing false or fraudulent information through the RRB Employer Reporting System is a violation of federal law
punishable by fine, imprisonment, or both.

Signature: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Date: _ _ _ _ _ _ _ _ __

Section C

"

Requested Action and Level of Access

1. Action (check appropriate box)

o

Add New User

o

Modify Access

Terminate Access

2. Explanation of the Levels of Access
R
U

Reader
Updater

A

Approver

X

Terminate

User can only view the forms. Restricts access to ~readonly.n
User has access to complete or "update" a form that changes the RRB's record of service and
compensation. User cannot submit the form to the RRB without authorization.
User has access to approve, update, certify and submit forms to the RRB. Level "An access is
appropriate for personnel who work independently and supervisory approval is. not needed.
User is prohibited from access to the ERS system or a particular form.

For additional information on levels of access, see Reporting Instructions to Employers, Part VIII, Chapter 2, or go to
www.rrb.gov/Employer Information and select "Rail Employers."
3. Check one box for each form. Note: Em 10 ee's level of access will a

Form BA-3, Annual Report of Creditable Compensation
Form BA-4, Report of Creditable Compensation Adjustments

/ for all em /0 ers listed in Section A.

OR
OR

Ou
Ou

OA
OA
OA
OA
OA
OA

Form BA-6a, Form BA-6 Address Report

Ou

Form BA-11 , Report of Gross Earnings
Form GL-129a, Record of Employer Determination on Employee
Protest of Service and Com ensation

, Form ID-4E, Notice of RUIA Claim Determinations

Form ID-4K, Prepayment Notice of Employees' Applications and
Claims for Benefits under RUIA
Section 0
Certification of Authority to Approve'Access

OR

Ox
Ox
Ox
Ox
Ox
Ox
x

The form must be signed by an official with signature authority to sign RRB forms for the employer(s) listed in Section A.
Signatures of two individuals are not required if the employee listed in Section B has authority to sig n RRB forms. The
head of the company and those persons designated on Form G-117A, Designation of Contact Official, have signature
authority. A contact official may assign Signature authority to a designee, but the RRB will verify with the contact official
an si natures other than those of a contact official.
.
'
1. Name: (print)
2. Title:
3. Telephone Number:

(

)

4. I have signature authority to approve this request and authorize the RRB to grant access as indicated above. I
understand that I am responsible for notifying the RRB if, in the future, this individual's access should be terminated.
Signature: -=======================,---=D:.:a::te:'::-===========-I
Section E
Group or Section E-Mail Address to Receive Notices
Complete this section only if you prefer to deSignate a group or section e-mail address as the default address for RRB
work notices, rather than the e-mail address listed in Section B above.
1. Default E-Mail Address:
2. If you have more than one group or section e-mail address, number each address and specify here which forms or
group of forms are associated with each address.

Questions?

Please contact the System Administrator at (312) 7514833, or the Quality Reporting Service Center at (312) 7514992.

Mail this completed application to: Quality Reporting Service Center
Railroad Retirement Board
844 N Rush Street
Chica 0, IL 60611-2092
We estimate this fonn takes an average of 10 to 20 minutes per response to complete, including the time needed for reviewing the instructions,
getting the needed data, and reviewing the completed fonn. Federal agencies may not conduct or sponsor, and respondents are not required
to respond to, a collection of infonnation unless it displays a valid OMB number. If you wish, send comments regarding the accuracy of our
estimate or any other aspect of this fonn, including suggestions for reducing the completion time, to: Chief of Infonnation Resources
Mana ament, Railroad Retirement Board, 844 N. Rush Street, Chica 0, IL 60611-2092.

For RRB Use: Access

Reviewed by:

Form BA-12 cpp-If)