Form GL-99 (11-09) GL-99 (11-09) Employer's Deemed Service Months Questionnaire

Form Approved

OMB No 3220-0156

United States of America
Railroad Retirement Board
1. BA No.
2. Social Security No.

Employer's
Deemed Service Months
Questionnaire

3. Name
4. PayrolllD No.
5. Date

11 .. t''''. LGIIL
The purpose of this form is to obtain information needed to determine whether the employee identified above can be credited
with additional service months (deemed service months) in accordance with provisions of Section 3(i) of the Railroad
Retirement Act. Our authority for requesting the information is Section 9 of the RRA. Reporting is mandatory under the law.
Failure to report or the making of a false or fraudulent report can result in criminal prosecution or civil penalties, or both.
We estimate this form takes an average of 2 minutes per response, including the time 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 any comments
regarding the accuracy of our estimates 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 St., Chicago. IL 60611-2092.
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Check the information entered by the Railroad Retirement Board in Items 1·6 and 8 for accuracy. If the information is
incorrect, correct it and enter your response based on the corrected information. Explain the correction in the Remarks
section. If the correction is to service months and/or compensation, you must file Form BA-4, Report of Creditable
Compensation Adjustments, and submit it with this questionnaire. If you have already filed the BA-4, enter the date filed in
the Remarks below.
When you have completed the form and signed the Certification Statement below, mail it to Assessment and Training,
Compensation and Employer Services, Protest Unit, 844 N. Rush St., Chicago, IL 60611·2092 or fax it to (312) 751·7190.
Under each month for which a service month has not been reported, enter "Y" if the employee had an employment
relationship in that month or UN" if the employee did not have an employment relationship. Refer to the Employer Reporting
'
Instructions for an <:OAI.lleu ,dthJ" of deemed service months.
6. Year
7. 1'<.'=tJv.1 LeU
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8. In Ei I ItJIVY"I<:OIIL
RI'!I:
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FEB

JAN

MAR

APR

MAY

JUL

AUG

SEP

OCT

NOV

DEC

TOTAL

9. Tier II Compensation:
10.

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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. I certify that,
to the best of my knowledge, the information which I have given is true, complete, and correct.

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Signature

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No.

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Title

Facsimile No.

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Date

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GL-99 (11-09)