DC-2A (10-12) Employee Representative's Status Report

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

CURRENT

FORM APPROVED
OMB NO. 3220-0014

1. SOCIAL SECURITY NO.

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

The information furnished on this form is used to determine if an
individual qualifies as an employee representative as prescribed in
Section 1(c) of the Railroad Retirement Act (RRA). The Railroad
Retirement Board's (RRB) authority for requesting this information is
Section 7(b)(6) of the RRA. Although you are not required to furnish this
information, the RRB will be unable to determine the individual's
qualifications for serving as an employee representative unless you
complete and return this form.

4.

5.

2. NAME (Last Name, First Name, and Middle Initial)

3. ADDRESS

Enter an "X" in the applicable box below:
(a)



(b)



I am an officer or official representative of a railway labor organization (other than an "employer" under the Railroad
Retirement Act) who is duly authorized and designated to represent employees in accordance with the Railway Labor
Act, as amended.
I am an individual regularly assigned to or regularly employed by an officer or official representative in connection with
the duties of the office. (If this box is "X'd" do not answer Items 5, 6, and 13.)

I was authorized to represent employees in negotiating with employers by: Election



Appointment



on _______________________________, for the period from _______________________________ to _____________________________.
DATE

DATE

DATE

6.

NAME OF EMPLOYEE GROUP REPRESENTED

7. TITLE OF POSITION

8.

NAME OF RAILWAY LABOR ORGANIZATION SERVED

9. NAME OF SUBORDINATE LODGE OR DIVISION OF
RAILWAY LABOR ORGANIZATION SERVED

10. DUTIES OF EMPLOYEE REPRESENTATIVE

11. CHIEF OFFICER OF RAILWAY LABOR ORGANIZATION

(c) ADDRESS

(a) NAME
(b) TITLE
12.

HEADQUARTERS' RECORDS OFFICER

(c) ADDRESS

(a) NAME
(b) TITLE
13. NAME OF LAST RAILROAD OR OTHER EMPLOYER UNDER THE RAILROAD RETIREMENT ACT BY WHICH YOU WERE EMPLOYED

14. 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-2A (10-12) PRIOR EDITIONS ARE OBSOLETE

INSTRUCTIONS FOR FILING FORM DC-2a
Individuals filing for status as an employee representative are required to complete and submit an employee
representative's status report to Policy and Systems, Compensation and Employer Services Center, 844 North
Rush Street, Chicago, Illinois 60611-2092.

Complete Form DC-2a as follows:
Item
1. Enter your social security number.
2. Enter your last name, first name, and middle initial.
3. Enter either your business or home address.
4. Enter an "X" in the box which indicates the basis for your employee representative status. If block (b) is
"X'd," make no entries in Items 5, 6, and 13.
5. If Item 4(a) is "X'd," this item must be completed. Enter an "X" in the box which indicates whether you
were elected or appointed to your position; enter the date of your election or appointment; enter the dates
of your appointment.
6. If Item 4(a) is "X'd," this item must be completed. Enter the name of the class, craft, or other group you
are authorized to represent.
7. Enter the title of your position as an employee representative.
8. Enter the full name of the railway labor organization which you serve, or the name of the railway labor
organization of which your subordinate lodge or division is a part.
9. Enter the full name of the subordinate lodge or division of the railway labor organization which you serve, if
any.
10. Enter your duties as an employee representative, by reference to articles of constitution by-laws, or
otherwise, state clearly your working hours, wages, and working conditions. If you are an employee
representative regularly assigned to or regularly employed by another employee representative, describe
your duties and enter the full name and title of the employee representative to whom you are assigned, or
by whom you are employed.
11. Enter on the appropriate line (a), (b), and (c) the name, title, and complete address of the chief officer of
your labor organization.
12. Enter on the appropriate line (a), (b), and (c) the name, title, and complete address of the officer in charge
of the headquarters’ records. If this is the same officer as shown in Item 11, make no entry.
13. If Item 4(a) is “X’d,” this item must be completed. Enter the full name of the last railroad or other
covered employer by which you were employed prior to the beginning of the period covered by this report.
14. 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 15 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-2A (10-12) PRIOR EDITIONS ARE OBSOLETE