GL-99 (proposed) Employer's Deemed Service Month Questionnairre

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0156
1. BA No.
2. Social Security No.

Employer’s
Deemed Service Months
Questionnaire

3. Name
4. Payroll ID No.
5. Date

Important Notices
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.

Employer Instructions
Check the information entered by the Railroad Retirement Board in Items 1-4, 6-7 and 9-10 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 Policy and Systems,
Compensation and Employer Services, Protest Unit, 844 N. Rush St., Chicago, IL 60611-2092 or fax it to (312) 751-7190.
6. For each month shown as a month not worked, check the appropriate “Yes” or “No” box in Item 7 to indicate if the employee
had an employment relationship in that month. Refer to the Employer Reporting Instructions for an explanation of deemed
service months.
Month(s) Not
Worked in

7. In Employment
Relationship?

JAN

FEB

MAR

APR

MAY

JUN

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

8. Service Months Reported:

9. Tier II Compensation:

JUL

Yes
No

AUG

SEP

OCT

NOV

DEC

Yes
No

Yes
No

Yes
No

Yes
No

Yes
No

ABD:

FOR
RRB
USE

Deemed Months:

10. REMARKS

11. CERTIFICATION STATEMENT

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.
Signature of Certifying Officer

Title of Certifying Officer

Telephone No.

Facsimile No.

(

(

)

Date

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GL-99 (xx-xx)