Form BA-6a (Internet) ( BA-6a (Internet) ( BA-6a, BA-6 Address Report (Internet Equivalent)

Form BA-6a, BA-6 Address Report

Employer BA Number:

Social Security Number:

Employee Last Name:

Employee First Name:

Employee Middle Initial:

Street Address Line 1:

Street Address Line 2:

City:

State:

ZIP Code:

Effective Date:

(This is the date you recorded the employee’s address. If the date is not know, leave this item blank.)

The information contained in this report is required by law under Section 7(b)6 of the Railroad Retirement Act and Section 209.12 of the Code of Federal Regulations. I affirm that to the best of my knowledge, the information I have given is true, complete, and correct. I understand that failure to report or the making of a false or fraudulent report can result in criminal prosecution or civil penalties, or both.

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Paperwork Reduction Act Notice

Display of Paperwork Reduction Act Notice

(For ERS Forms BA-4 and BA-6a)

Paperwork Reduction Act Notice

We estimate this form takes an average of 12 to 17 minutes per response to complete, including the time needed 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 comments regarding the accuracy of our estimate 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 STREET, CHICAGO, IL 60611-2092.