Form Ba-11 - Report Of Gross Earnings - Railroad Retirement

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FORM APROVED
UNITED STATES OF AMERICA
OMB NO. 3220-0132
RAILROAD RETIREMENT
1. YEAR
2. EMPLOYER BA NO.
3. PAGE NUMBER
4. TYPE OF REPORT
REPORT OF GROSS EARNINGS
(Monthly, Quarterly or
(SEE INSTRUCTIONS FOR COMPLETING AND MAILING THIS FORM ON REVERSE SIDE)
Annual Breakdown)
The purpose of this report is to obtain the gross earnings for a sample of employees. This information
is required for computation of the Financial Interchange with the Social Security Administration and the
Centers for Medicare & Medicaid Services. The report is required by law under Section 7(b)(6) of the
5a. NAME OF EMPLOYER
Railroad Retirement Act. Failure to report or the making of a false or fraudulent report can result in
criminal prosecution or civil penalties, or both.
5b. OTHER NAME, IF ANY
FORM G-440, REPORT SPECIFICATIONS SHEET, MUST ACCOMPANY THIS FORM.
GROSS EARNINGS AMOUNTS
6.
7.
8(a)
8(b)
8(c)
8(d)
8(e)
8(f)
8(g)
8(h)
8(i)
8(j)
8(k)
8(l)
ANNUAL
EMPLOYEE
EMPLOYEE
NAME
1ST
2ND
3RD
4TH
SOCIAL
(Last Name;
QUARTER
QUARTER
QUARTER
QUARTER
SECURITY
First Name; and
NUMBER
JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
Middle Initial)
For RRB
11-19
20-55
56-64
65-73
74-82
83-91
92-100
101-109
56-64
65-73
74-82
83-91
92-100
101-109
Use Only
Form BA-11 (01-08)

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