Supplemental Pension Report

CURRENT
United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0089

Employer's Supplemental
Pension Report
2

Railroad Contact Official's Name and Address

SECTION 1 - IDENTIFYING INFORMATION
1 Social Security Number
3 Name
4 Date Released

5 BA Number

,
6 Job Title or Category
Salaried
Non-Agreement
Agreement (Union)
Other

Fax Number:

SECTION 2 – GENERAL INFORMATION FOR THE EMPLOYER
For assistance in completing this form, read Part VI, Chapter 6, of the Employer Reporting Instructions located on our website at
www.rrb.gov, which provides information about supplemental annuities and how they are affected by railroad pensions. Also read
the “Important Notices” on the next page. Type or print legibly in ink. If you need more space than is provided, use Section 5,
Remarks. Based on your answer to a question, you may be told to “Go to” another item. If no “Go to” instructions are given,
answer the next item in order. Do not skip any items unless directed to do so.

SECTION 3 – EMPLOYEE’S PENSION ENTITLEMENT
7

Was the employee covered under either a
defined benefit pension plan or money
purchase pension plan with your railroad?

Yes – Go to Section 4
No – Go to Section 6

SECTION 4 – EMPLOYEE’S PENSION BENEFIT INFORMATION
8

Enter the name of the pension plan.

9

How is the plan funded?

Employer contributions only – Go to Item 10
Both employer and employee contributions – Go to Item 10
Employee contributions only – Go to Section 6

Is the monthly pension reduced by the
amount of the RRB supplemental annuity?

Yes it is reduced
by all of the supplemental annuity - Go to Section 6
by part of the supplemental annuity - Enter percentage:
No it is not reduced

a Is the employee currently eligible for the
pension?

Yes – Go to Item 11b
No – Go to Section 6 (IMPORTANT: Notify the RRB when the employee
becomes eligible for or begins receiving the pension.)

b Select which applied to the employee.

Filed for the pension – Go to Item 12
Elected to defer distribution from the pension account – Go to Item 14

Indicate the type of pension payment.

Monthly pension – Go to Item 13
Lump sum elected in lieu of a monthly pension – Go to Item 14
Lump sum paid under the plan’s small benefit provision – Go to Item 15

10

11

12

%

13 Monthly Pension Information
a Enter the date the employee began,
or will begin, receiving the monthly
pension. If the date is unknown,
enter an estimated date.
Month

Day

Year

b Is the amount of the monthly pension
based on the employer’s contributions
greater than $43.00?
Yes – Go to Section 6

c Enter the amount of the monthly
pension based on the employer’s
contributions then go to Section 6.

_____________________

No

G-88P (12-17)

14 Lump Sum Elected In Lieu of a Monthly Pension or Deferred Distribution
a Enter the date the employee would
b Would the amount of the monthly
have begun receiving the monthly
pension based on the employer’s
pension if the lump sum had not
contributions have been greater than
been elected.
$43.00?
Month

Day

Year

Yes – Go to Section 6

c Enter the amount of the monthly
pension based on the employer’s
contributions then go to Section 6.

_____________________

No
15 Lump Sum Paid Under Plan’s Small Benefit Provision
a Enter the date the lump sum was
paid.
Month

Day

b Enter the total amount of the lump sum.

c Enter the amount of the lump sum
based on the employer’s
contributions.

_______________________

_____________________

Year

SECTION 5 – REMARKS
You may use this section to enter any additional information that you feel may be important to include. Be sure to include the item
number of any answer you wish to continue.

SECTION 6 – EMPLOYER CERTIFICATION BY SUPPLEMENTAL ANNUITY CONTACT OFFICIAL
Always complete this item. I certify that I have examined this report, that it is made in good faith and that to the best of my
knowledge and belief all entries made herein are true and correct, and in accordance with the laws and regulations applicable
hereto. I understand that providing false or fraudulent information or failing to provide required information is a violation of federal law
punishable by fine, imprisonment or both.

_____________________________________________________
Signature of Railroad Contact Official
Business Telephone Number

(_____)_______________

_____________________________________________
Title
Date
DO NOT WRITE IN THIS AREA -- FOR RRB USE ONLY

Return this form to:

US Railroad Retirement Board
844 N. Rush Street, RSBD-RIS
Chicago, IL 60611-1275
Fax Number: (312) 751-7192

Date Reply Received at RRB
Received By

IMPORTANT NOTICES
PAPERWORK REDUCTION ACT NOTICE
The information requested on this form is needed to determine if a reduction is required to the supplemental annuities of your retired
employees under Section 2(h) (2) of the Railroad Retirement Act (RRA) (45 USC 231a(h)(2)). Furnishing this information is required
by law, (Section 7(b)(6) of the RRA (45 USC 231f(b)(6))).
We estimate this form takes an average of 8 minutes 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, US Railroad Retirement Board, 844 N. Rush St, Chicago, Illinois 60611-1275.

G-88P (12-17)