Designation of Contact Officials

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Proposed
Form Approved
OMB No. 3220-0200

United States of America
Railroad Retirement Board
EMPLOYER NAME

DESIGNATION OF CONTACT OFFICIALS

(See Instructions for Completing and Submitting This Form on Page 3)

EMPLOYER BA NUMBER

DATE

(1) EXECUTIVE OFFICER

Executive of the organization to whom all general correspondence should be addressed with respect to administration of RRA and RUIA.

NAME

TITLE

STREET ADDRESS LINE 1

STREET ADDRESS LINE 2

CITY, STATE, & ZIP

TELEPHONE NUMBER

FACSIMILE NUMBER

EMAIL ADDRESS

(2) SERVICE AND COMPENSATION

Responsible for submitting service and compensation reports, including Forms BA-3, BA-4, BA-6A, BA-9, BA-11, BA-15, and G-440. Handles
correspondence and other matters related to service and compensation reporting, and RUIA tax contributions, including Forms AA-12, DC-1, G-88A.1,
G-88A.2, GL-4, GL-4A, GL-24, GL-77A, GL-99, GL-129, GL-129A, GL-130, GL-131, GL-132, GL-132A, ID-40Q, ID-40R/S, UI-41, & UI-41A.

NAME

TITLE

STREET ADDRESS LINE 1

STREET ADDRESS LINE 2

CITY, STATE, & ZIP

TELEPHONE NUMBER

FACSIMILE NUMBER

EMAIL ADDRESS

(3) RAILROAD RETIREMENT AWARDS

May receive notices of RRA annuity awards. Also handles correspondence related to annuity awards, including Forms G-73A.1, RL-13G, and RL-27.

NAME

TITLE

STREET ADDRESS LINE 1

STREET ADDRESS LINE 2

CITY, STATE, & ZIP

TELEPHONE NUMBER

FACSIMILE NUMBER

EMAIL ADDRESS

(4) SUPPLEMENTAL ANNUITY

Handles correspondence related to supplemental annuity awards, including Form G-88p.

NAME

TITLE

STREET ADDRESS LINE 1

STREET ADDRESS LINE 2

CITY, STATE, & ZIP

TELEPHONE NUMBER

FACSIMILE NUMBER

EMAIL ADDRESS

(5) RRA ANNUITY ESTIMATES

Receives reports of annuity estimates for employees who have at least 120 months of creditable railroad service or at least 60 months if service was
rendered after 1995.

NAME

TITLE

STREET ADDRESS LINE 1

STREET ADDRESS LINE 2

CITY, STATE, & ZIP

TELEPHONE NUMBER

FACSIMILE NUMBER

EMAIL ADDRESS

Form G-117A (XX-XX)

UNITED STATES RAILROAD RETIREMENT BOARD

2

Form Approved OMB No. 3220-0200

(6) SECTION 2(f) – RUIA

Receives and submits notices related to the reimbursement of RUIA benefits under Section 2(f) of the RUIA, including Form ID-3U.

NAME

TITLE

STREET ADDRESS LINE 1

STREET ADDRESS LINE 2

CITY, STATE, & ZIP

TELEPHONE NUMBER

FACSIMILE NUMBER

EMAIL ADDRESS

(7) SECTION 2(f) BILL PAYMENT – RUIA

Receives as well as makes payments on Pay for Time Lost and Guarantee Payments under Section 2(f) of RUIA either through PAY.gov or by paper
billing documents.

NAME

TITLE

STREET ADDRESS LINE 1

STREET ADDRESS LINE 2

CITY, STATE, & ZIP

TELEPHONE NUMBER

FACSIMILE NUMBER

EMAIL ADDRESS

(8) SECTION 12(o) – RUIA

Receives notices of lien and handles various types of correspondence under Section 12(o) of RUIA, including Forms ID-30B and ID-3S.

NAME

TITLE

STREET ADDRESS LINE 1

STREET ADDRESS LINE 2

CITY, STATE, & ZIP

TELEPHONE NUMBER

FACSIMILE NUMBER

EMAIL ADDRESS

(9) SECTION 12(o) BILL PAYMENT – RUIA

Receives and makes payment on bills for Personal Injury Cases under Section 12(o) of RUIA either through PAY.gov or by paper billing documents.

NAME

TITLE

STREET ADDRESS LINE 1

STREET ADDRESS LINE 2

CITY, STATE, & ZIP

TELEPHONE NUMBER

FACSIMILE NUMBER

EMAIL ADDRESS

(10) TIER I TAX REPORT – RUIA

Receives notices of Tier I taxes due on RUIA sickness benefits creditable as Tier I compensation, including Forms ID-6 and ID-6Y.

NAME

TITLE

STREET ADDRESS LINE 1

STREET ADDRESS LINE 2

CITY, STATE, & ZIP

TELEPHONE NUMBER

FACSIMILE NUMBER

EMAIL ADDRESS

(11) PREPAYMENT CLAIMS VERIFICATION – RUIA

Receives notices of applications and claims filed under the RUIA, notices of RUIA claim determination, and requests for separation allowance
information, including Forms ID-4K, ID-4E and ID-13E

NAME

TITLE

STREET ADDRESS LINE 1

STREET ADDRESS LINE 2

CITY, STATE, & ZIP

TELEPHONE NUMBER

FACSIMILE NUMBER

EMAIL ADDRESS

Form G-117A (XX-XX)

UNITED STATES RAILROAD RETIREMENT BOARD

3

Form Approved OMB No. 3220-0200

(12) RAILROAD HIRING

Handles matters pertaining to the employee placement program under the RUIA.

NAME

TITLE

STREET ADDRESS LINE 1

STREET ADDRESS LINE 2

CITY, STATE, & ZIP

TELEPHONE NUMBER

FACSIMILE NUMBER

EMAIL ADDRESS

(13) DISABILITY

Handles Forms G-3EMP, G-251 and G-251A requests for job duties.

NAME

TITLE

STREET ADDRESS LINE 1

STREET ADDRESS LINE 2

CITY, STATE, & ZIP

TELEPHONE NUMBER

FACSIMILE NUMBER

EMAIL ADDRESS

(14) VERIFICATION OF EMPLOYER GROUP HEALTH PLAN

Receives correspondence related to coverage under an employer’s Group Health Plan including Form RL-311-F.

NAME

TITLE

STREET ADDRESS LINE 1

STREET ADDRESS LINE 2

CITY, STATE, & ZIP

TELEPHONE NUMBER

FACSIMILE NUMBER

EMAIL ADDRESS

(15) CERTIFICATION

The above officials of this employer are authorized to serve in the capacities indicated and to act as trusted referees for the RRB in accordance with
National Institute of Standards and Technology Special Publication 800-63A guidelines for online reporting access.

PRINT NAME
TITLE

SIGNATURE
TELEPHONE NUMBER

DATE

INSTRUCTIONS
The form must be signed by an official with signature authority to sign RRB forms for the employer listed on the top right of page 1. The
head of the company or any person designated as a Contact Official on a previous Form G-117A, Designation of Contact Official, has
signature authority. Provide signature, title, telephone number, and date.
The information requested on this form is used to both establish an RRB contact official for the items described above, 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(s)
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. Completed forms can be emailed to [email protected] or mailed to the Railroad
Retirement Board, Office of Programs, P&S - Quality Reporting Service Center, 844 North Rush Street, Chicago, Illinois 60611-1275.
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: Railroad Retirement
Board, ATTN: Bureau of Information Services/Policy & Compliance, 844 N. Rush Street., Chicago, IL 60611-1275.

Form G-117A (XX-XX)