G-440 (proposed) Report Specification Sheet

Form Approved

UNITED STATES OF AMERICA

OMB No. 3220-0008

RAILROAD RETIREMENT BOARD

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

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. Do not complete this form if you are
using the Employer Reporting System (ERS) to submit Forms
BA-3, BA-4, BA-6a and BA-11 ,

1 CORPORATE NAME AND ADDRESS OF EMPLOYER

3 DATE REPORT BEING SUBMITTED 14 EMPLOYER SA NUMBER

,

5 PERSON TO CONTACT REGARDING THIS REPORT
6mLE

2 OTHER EMPLOYER NAME, IF ANY

7 TELEPHONE NUMBER

18 FACSIMILE NUMBER

9 E-MAIL ADDRESS

0
D

I AM NOT SUBMITTING AN ANNUAL REPORT BECAUSE MY COMPANY HAS NO EMPLOYEES • (Go to Item 14)
I AM NOT SUBMITTING A GROSS EARNINGS REPORT BECAUSE MY COMPANY HAS NO EMPLOYEES WITH A SOCIAl SECURITY
NUMBER ENDING IN ''3~," • (Go to Item 14)

10 TYPE OF REPORT (CHECK ONLY ONE)

D

11 REPORT MEDIUM (CHECK ONLY ONE)

ANNUAL REPORT (FORM BA-3); REPORT INCLUDES:
(Check ALL that apply)

o

o Regular Compensation and Service
o Sick Pay and Miscellaneous Compensation
o Employee Addresses

ADJUSTMENT REPORT (FORM BA-4); REPORT INCLUDES:

D
D
D
D

(Check ALL that apply)

o Regular Compensation and Service
o Sick Pay and Miscellaneous Compensation

D

o

D

MAGNETIC TAPE CARTRIDGE
CD-ROM
FTP (File Transfer Protocol) INTERCHANGE
SECURE E-MAIL

NOTE: Report Record Lengths:
Fonm BA-3 300 Fonm BA-4
Fonm BA-6A 180 Fonm BA-9
Fonm BA-11 120

=

=

=

SEPARATION ALLOWANCE/SEVERANCE PAY REPORT (FORMBA-9)
GROSS EARNINGS REPORT (FORM BA-11)
ADDRESS REPORT (FORM BA-SA)

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

0

NONE

D

=200
=120

PAPER - Go to Item 13.

D STANDARD IBM D NON-STANDARD HEADERITRAILER

o

LEADING TAPE MARK

(B) FILE NAME:
(C) REEL NUMBER(S)

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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 infonmation
to misrepresent a fact material to detenmining a right to payment under the Railroad Retirement Act or the Railroad Unemployment
Insurance Act. I certify that, to the best of my knowledge, the infonmation which I have given is true, complete, and correct.
SIGNATURE OF CERTIFYING OFFICERIDATE
REMARKS

Fonn GMO ~.:'fJlb

Page

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RECAPITULATION SHEET
NOTE: If more than 15 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: 15 pages from one report can be recapped
on

a single Recapitulation Sheet.

Item 3.
NOTE:
Item 4.
Item 5.

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.
For Items 4, 5, and 6, below, enclose negative amounts in parentheses, i.e., "(10, 000. OO}. ..
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.
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.
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1. Check One: [ ] Form BA-3, Annual Report
Form BA-4' Adjustment Report
2.
3.
4. NET COMPENSATION TOTALS
RUIA COMPENSATION
RRA COMPENSATION
REPORT
REPORT
b.
c.
d.
e.
f.
PAGE
RECORD a.
QUALIFYING
MAXIMUM BENEFIT
MISCELLANEOUS
#
COUNT
TIER
I
TIER
II
SICK PAY
AMOUNT
AMOUNT
COMPENSATION
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Page Totafs

6.

Recap Sheet
Grand Totals

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completion time, to CHIEF OF INFORMATION RESOURCES MANAGEMENT, RAILROAD RETIREMENT BOARD, 844 N. RUSH STREET, CHICAGO, IL 60611·2092.
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Form G-440

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