Form G-117a (10-13)

Form G-117a (10-13).pdf

Employer Reporting

Form G-117a (10-13)

OMB: 3220-0005

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CURRENT

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0200

EMPLOYER NAME

DESIGNATION OF CONTACT OFFICIALS
(See Instructions for Completing and Mailing This Form on Reverse Side)

EMPLOYER BA NUMBER

(1) EXECUTIVE OFFICER

(2) SERVICE AND COMPENSATION

NAME

NAME

TITLE

TITLE

STREET ADDRESS

STREET ADDRESS

CITY, STATE & ZIP CODE

CITY, STATE & ZIP CODE

TEL NO.

E-MAIL ADDRESS

TEL NO.

FAX NO.

FAX NO.

(3) RAILROAD RETIREMENT AWARDS

(4) RRA ANNUITY ESTIMATE

NAME

NAME

TITLE

TITLE

STREET ADDRESS

STREET ADDRESS

CITY, STATE & ZIP CODE

CITY, STATE & ZIP CODE

TEL NO.

E-MAIL ADDRESS

TEL NO.

FAX NO.

FAX NO.

(5) SECTION 2(F) - RUIA

(6) SECTION 12(O) - RUIA

NAME

NAME

TITLE

TITLE

STREET ADDRESS

STREET ADDRESS

CITY, STATE & ZIP CODE

CITY, STATE & ZIP CODE

TEL NO.

E-MAIL ADDRESS

TEL NO.

DATE

E-MAIL ADDRESS

E-MAIL ADDRESS

E-MAIL ADDRESS

FAX NO.

FAX NO.

(7) TIER 1 TAX REPORT - RUIA

(8) PREPAYMENT CLAIMS VERIFICATION - RUIA

NAME

NAME

TITLE

TITLE

STREET ADDRESS

STREET ADDRESS

CITY, STATE & ZIP CODE

CITY, STATE & ZIP CODE

TEL NO.
FAX NO.

E-MAIL ADDRESS

TEL NO.

E-MAIL ADDRESS

FAX NO.

Form G-117a (10-13)

(9) RAILROAD HIRING

(10) DISABILITY

NAME

NAME

TITLE

TITLE

STREET ADDRESS

STREET ADDRESS

CITY, STATE & ZIP CODE

CITY, STATE & ZIP CODE

TEL NO.

E-MAIL ADDRESS

FAX NO.

TEL NO.

E-MAIL ADDRESS

FAX NO.

(11) STREET ADDRESS

The above officials of this employer are authorized to serve in the capacities indicated.
(12) SIGNATURE
PRINT NAME
TITLE

DATE

INSTRUCTIONS
The information requested on this form is used to both establish a Railroad Retirement Board (RRB) contact official for the items described
below and to change a contact official or an official's address. One contact official may be designated to serve in all capacities. If one contact
official is designated to serve in all capacities, complete box one and write "same" in all other boxes. Please notify the RRB immediately of any
change in official or address. Include, on an attachment, the names of subsidiary or affiliated companies for which the above designated
contact officials are authorized to act and any other information related to the designations. If different contact officials are to be designated for
subsidiary or affiliated companies, use a separate Form G-117a. Please execute and return promptly to the Railroad Retirement Board, Office
of Programs, P&S, Compensation and Employer Services Center, 844 North Rush Street, Chicago, Illinois 60611-2092.
Items
(1)
(2)

(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)

Contact Official and/or Description
Executive Officer - Executive of the organization to whom all general correspondence should be addressed with respect to
administration of RRA and RUIA.
Service and Compensation - Responsible for submitting service and compensation reports, including Forms BA-3, BA-4, BA-6A,
BA-9, BA-11, and DC-1. Handles correspondence and other matters related to service and compensation reporting, and RUIA tax
contributions, including Forms AA-12, G-88A.1, G-88A.2, GL-4, GL-4A, GL-4B, GL-24, GL-77A, GL-99, GL-129, GL-130, GL-131,
GL-132, ID-40Q, ID-40R/S, and UI-41A.
Railroad Retirement Awards - May receive notices of RRA annuity awards. Also handles correspondence related to annuity awards,
including Forms G-73A.1, RL-13G, RL-27, and G-88P.
RRA Annuity Estimate - Receives reports of annuity estimates for employees with 120 or more service months.
Section 2(f) - RUIA - Receives and submits notices related to the reimbursement of RUIA benefits under Section 2(f) of the RUIA,
including Forms ID-30 and ID-3U.
Section 12(o) - RUIA - Receives notices of lien under Section 12(o) of RUIA and handles various types of correspondence related to
Section 12(o), including Forms ID-30B and ID-3S.
Tier 1 Tax Report - RUIA - Receives notices of Tier 1 taxes due on RUIA sickness benefits creditable as Tier 1 compensation (Form
ID-6).
Prepayment Claims Verification - RUIA - Receives notices of applications and claims filed under the RUIA (Form ID-4K) and notices
of RUIA claim determinations (Form ID-4E).
Railroad Hiring - Handles matters pertaining to the employee placement program under the RUIA.
Disability - Handles Form G-251 requests for job duties.
Street Address - If contact official address is P.O. Box, enter primary railroad street address.
Enter your signature, title, and the date signed.

PAPERWORK REDUCTION ACT/PRIVACY ACT NOTICES
The Railroad Retirement Board (RRB) is authorized to collect the information requested on this form under Section 7(b)6 of the Railroad
Retirement Act of 1974 and Section 5(b) of the Railroad Unemployment Insurance Act. Although you are not required to provide the requested
information, cooperation in doing so will assist the RRB in providing information to employers to meet their fiscal and regulatory obligations
toward benefit programs as well as support the RRB administration of those programs.
We estimate this form takes an average of 15 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.

Form G-117a (10-13)


File Typeapplication/pdf
File TitleForm G-117a (10-13)
SubjectForm Approved OMB No. 3220-0200
AuthorDana Hickman
File Modified2013-10-22
File Created2013-10-22

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