Form DC-2 (10-12) DC-2 (10-12) Employee Representative's Report of Compensation

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

FORM APPROVED
OMB NO. 3220-0014
2. REPORTING LODGE NO.

1. REPORT
FOR YEAR

EMPLOYEE REPRESENTATIVE'S
REPORT OF COMPENSATION
(SEE INSTRUCTIONS FOR COMPLETING AND
MAILING THIS FORM ON REVERSE SIDE)

(T/P 2—5)

(T/P 7-10)

(T/P 11—20)

3. SOCIAL SECURITY NO.

The purpose of this report is to obtain the creditable
compensation and service needed for payment of benefits under
the provisions of the Railroad Retirement Act and is required by
law (Section 9, Railroad Retirement Act of 1974).
Failure to report or the making of a false or fraudulent report can
result in criminal prosecution or civil penalties, or both.

(T/P 21—29)

4. LAST NAME

F.I.

(T/P 30—49)

(T/P 50—64)

M.I.

(T/P 65)

5. ADDRESS
THIS REPORT IS TO BE FILED ONLY IF:
1.

2.

You are an officer or official representative of a Railway Labor
Organization (other than an "Employer" under the Railroad
Retirement Act), and
a. are duly authorized and designated to represent
employees in accordance with the Railway Labor Act, as
amended, in negotiating with employers about rates of pay,
rules, or working conditions, and
b. have been in the service of an "Employer" under the
Railroad Retirement Act; or
You are regularly assigned to or regularly employed by the
officer or official representative described above, in connection
with the duties of that office.

8a. TITLE OF EMPLOYEE
REPRESENTATIVE POSITION(S)

8b.
J
A
N

6. NAME OF RAILWAY LABOR ORGANIZATION SERVED

7. NAME OF SUBORDINATE LODGE OR DIVISION OF THE ORGANIZATION
SERVED

MONTHS EMPLOYED:
ENTER AN "X" IN EACH MONTH EMPLOYED

8c.

F
E
B

M
A
R

A
P
R

M
A
Y

J
U
N

J
U
L

A
U
G

S
E
P

O
C
T

N
O
V

D
E
C

85

86

87

88

89

90

91

92

93

94

95

8d.

TOTAL
SERVICE
MONTHS

8e.
TIER I

TIER II

(1)

(2)

9-11b.

FOR RRB USE ONLY

9.
84

10.

11a.

96—97

11b.
98—105

108—115

TOTALS
12. ARE THE DUTIES OF THE POSITION YOU NOW OCCUPY THE SAME AS THE DUTIES
FOR THE PREVIOUS YEAR?
YES
NO - EXPLAIN DIFFERENCES IN SPACE BELOW.





13. THE RECORD FROM WHICH THIS REPORT
WAS MADE IS IN THE CUSTODY OF:
NAME AND TITLE

ADDRESS

14. EMPLOYEE REPRESENTATIVE QUARTERLY RAILROAD RETIREMENT TAX RETURNS, FORMS CT-2, WERE FILED WITH THE DISTRICT
DIRECTOR OF INTERNAL REVENUE AT THE ADDRESS SHOWN BELOW:

(CITY)
(STATE)
(ZIP CODE)
15. KNOWING THAT ANYONE WHO MAKES A FALSE OR FRAUDULENT STATEMENT FOR THE PURPOSE OF OBTAINING BENEFITS FROM THE
RRB IS COMMITTING A CRIME PUNISHABLE UNDER FEDERAL LAW, I CERTIFY THAT THE INFORMATION IS TRUE, CORRECT, AND
COMPLETE.
SIGNATURE OF EMPLOYEE REPRESENTATIVE
TELEPHONE NUMBER
FACSIMILE NUMBER
DATE SIGNED

FORM DC-2 (10-12) PRIOR EDITIONS ARE OBSOLETE

INSTRUCTIONS FOR FILING FORM DC-2
Each year, by the last day of February, employee representatives are required to submit an annual report of creditable
service and compensation earned in the previous calendar year to Policy and Systems, Compensation and Employer
Services Center, 844 North Rush Street, Chicago, Illinois 60611-2092. Upon termination of employee representative
status, the last report of compensation shall be marked "Final Report."

Complete Form DC-2 as follows:
Item
1.

Enter the calendar year for which the report is made.

2.

Enter the reporting lodge number. If unknown, leave blank.

3.

Enter your social security number.

4.

Enter your last name, followed by your first and middle initials.

5.

Enter either your business or home address.

6.

Enter the full name of the railway labor organization which you serve or of which your subordinate lodge or division is
a part.

7.

Enter the full name of the subordinate lodge or division of the railway labor organization which you serve, if any.

8a.

Enter on line(s) (1) and (2) the title(s) of your position(s) as an employee representative.

b.

Enter an "X" to indicate the month(s) in which you have earnings. If service is reported for all 12 months, this detail
may be omitted.

c.

Enter the total service months. Add the number of "X's" and enter the total for each position.

d.

Enter your creditable Tier I compensation, up to the annual Tier I maximum.

e.

Enter your creditable Tier II compensation, up to the annual Tier II maximum.

9-11. No entry. For RRB use only.
12.

Enter an "X" in the box which indicates whether or not your duties have changed. If your answer is "No," explain the
difference in duties in the space provided.

13.

Enter in the appropriate box, the name, title, and address of the person who has custody of the records from which
this report was made.

14.

Enter the city, state, and zip code of the Internal Revenue Office with which you file your Form CT-2, Employee
Representative's Quarterly Railroad Retirement Tax Return.

15.

Enter your signature, telephone number, facsimile number (if applicable), and the date signed.

PAPERWORK REDUCTION ACT NOTICE
We estimate this form takes an average of 30 minutes per response to complete, 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 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 North Rush Street, Chicago, Illinois 60611-2092.

FORM DC-2 (10-12) PRIOR EDITIONS ARE OBSOLETE