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

UNITED STATES OF AMERICA FORM APPROVED

RAILROAD RETIREMENT BOARD OMB NO. 3220-0014

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

1. REPORT FOR YEAR

2. REPORTING LODGE NO.

(T/P 2—5)

(T/P 7-10)

 (T/P 11—20)

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.

3. SOCIAL SECURITY NO.

(T/P 21—29)

4. LAST NAME

F.I.

M.I.

(T/P 30—49)

(T/P 50—64)

(T/P 65)

THIS REPORT IS TO BE FILED ONLY IF: 1. You are an officer or official representative of a Railway Labor Organization (other than an "Employer" under the Railroad Retirement Act), and 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 have been in the service of an "Employer" under the Railroad Retirement Act; or 2. You are regularly assigned to or regularly employed by the officer or official representative described above, in connection with the duties of that office.

5. ADDRESS

6. NAME OF RAILWAY LABOR ORGANIZATION SERVED

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

8a. TITLE OF EMPLOYEE REPRESENTATIVE POSITION(S)

8b. MONTHS EMPLOYED: ENTER AN "X" IN EACH MONTH EMPLOYED

8c.  TOTAL SERVICE MONTHS

8d. TIER I

8e. TIER II

J A N

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

(1)

(2)

9-11b. FOR RRB USE ONLY TOTALS

9.

10.

11a.

11b.

84

85

86

87

88

89

90

91

92

93

94

95

96—97

98—105

108—115

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

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 60611-1275. Upon termination of employee representative status, the last report of compensation shall be marked "Final Report." Complete Form DC-2 as follows: Item Enter the calendar year for which the report is made. Enter the reporting lodge number. If unknown, leave blank. Enter your social security number. Enter your last name, followed by your first and middle initials. Enter either your business or home address. Enter the full name of the railway labor organization which you serve or of which your subordinate lodge or division is a part. 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. No entry. For RRB use only. 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. 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. 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. 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: Associate Chief Information Officer for Policy and Compliance, Railroad Retirement Board, 844 North Rush Street, Chicago, Illinois 60611-1275.

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