G-440 (01-12)

Form Approved
OMB No. 3220-0008

UNITED STATES OF AMERICA
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
5

4 EMPLOYER BA NUMBER

PERSON TO CONTACT REGARDING THIS REPORT

6 TITLE
2 OTHER EMPLOYER NAME, IF ANY

7 TELEPHONE NUMBER

8 FACSIMILE NUMBER

9 E-MAIL ADDRESS
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 “30.”  (Go to Item 14)

10 TYPE OF REPORT (CHECK ONLY ONE)

11 REPORT MEDIUM (CHECK ONLY ONE)

ANNUAL REPORT (FORM BA-3); REPORT INCLUDES:
(Check ALL that apply)
Regular Compensation and Service
Sick Pay and Miscellaneous Compensation
Employee Addresses
ADJUSTMENT REPORT (FORM BA-4); REPORT INCLUDES:
(Check ALL that apply)
Regular Compensation and Service
Sick Pay and Miscellaneous Compensation

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

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

NOTE: Report Record Lengths:
Form BA-3 = 300 Form BA-4 = 200
Form BA-6A = 180 Form BA-9 = 120
Form BA-11 = 120
PAPER - Go to Item 13.

ADDRESS REPORT (FORM BA-6A)

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

NONE

STANDARD IBM

NON-STANDARD HEADER/TRAILER

LEADING TAPE MARK

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

THIS SECTION IS FOR RRB USE ONLY

DATE RECEIVED IN CESC:

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 information
to misrepresent a fact material to determining 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 information which I have given is true, complete, and correct.
SIGNATURE OF CERTIFYING OFFICER/DATE

REMARKS

Form G-440 (01-12)

Page ______ of ______

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. 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.
NOTE: For Items 4, 5, and 6, below, enclose negative amounts in parentheses, i.e., "(10,000.00)."
Item 4. 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.
Item 5. 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.
Multi-page recapitulation sheet - Summarize Item 5 from each sheet and then enter sum total.
1. Check One:
2.

Form BA-3, Annual Report

3.
REPORT
PAGE
#

REPORT
RECORD
COUNT

Form BA-4, Adjustment Report

4. NET COMPENSATION TOTALS
RUIA COMPENSATION
a.

QUALIFYING
AMOUNT

b.

MAXIMUM BENEFIT
AMOUNT

RRA COMPENSATION
c.

d.

TIER I

e.

TIER II

MISCELLANEOUS
COMPENSATION

f.

SICK PAY

(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)

5. Recap Sheet
Page Totals

0

6. Recap Sheet

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

Grand Totals
We estimate this form takes from 15 to 75 minutes per response, including the time for reviewing 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 completion time, to CHIEF OF INFORMATION RESOURCES MANAGEMENT, RAILROAD RETIREMENT BOARD, 844 N. RUSH STREET, CHICAGO, IL 60611-2092.

Form G-440 (01-12)