Report Of Creditable Compensation Adjustments - Railroad Retirement Board

UNITED STATES OF AMERICA

FORM APPROVED

RAILROAD RETIREMENT BOARD

OMB NO. 3220-0008

REPORT OF CREDITABLE COMPENSATION ADJUSTMENTS

(SEE INSTRUCTIONS FOR COMPLETING AND MAILING THIS FORM ON REVERSE SIDE)

The information contained in this report, which is required by law under Section 9 of the Railroad Retirement Act (RRA) and Section 6 of the Railroad Unemployment Insurance Act (RUIA), is needed to adjust compensation and service creditable under the RRA and

RUIA. Failure to report or the making of a false or fraudulent report can result in criminal prosecution or civil penalties, or both.

FORM G-440, REPORT SPECIFICATIONS SHEET, MUST ACCOMPANY THIS FORM.

1. MONTH/YEAR SUBMITTED

2. EMPLOYER BA NO.

3. PAGE NO.

4a. CORPORATE NAME OF EMPLOYER

4b. OTHER NAME, IF ANY

FOR RRB USE ONLY

2—5

21—29

30—65

66—72

75—81

84—95

96—97

98—105

108—115

125—132

135—142

118—122

5.

6.

7.

8.

9.

10.

11.

12.

13.

EMPLOYEE

RUIA COMPENSATION

MONTHS ADJUSTED

RRA COMPENSATION

EMPLOYEE

ADJUST

LAST

NAME

TOTAL

SOCIAL

TYPE

a.

b. MAXIMUM

a.

b.

c.

d.

DAILY

YEAR

(Last Name;

J

F

M

A

M

J

J

A

S

O

N

D

SM

SECURITY

I = Incr

CREDITABLE

TIER I

TIER II

MISCELLANEOUS

SICK PAY

PAY

First Name; and

A

E

A

P

A

U

U

U

E

C

O

E

BENEFIT

ADJ.

NUMBER

D = Decr

AMT. ADJ.

ADJ.

ADJ.

ADJ.

ADJ

RATE

N

B

R

R

Y

N

L

G

P

T

V

C

Middle Initial)

AMT. ADJ.

(1)

(2)

(3)

(4)

(7)

(6)

(7)

(8)

(9)

(10)

(11)

(12)

(

)

13

(

)

14

(15)

14. Record

15. Enter the compensation total amounts below for Items 9a through 12d. Include a decimal point and two digits representing cents ($$$$$$.¢¢). Enclose negative total amounts in parentheses (10000.00).

Count

9a Total RUIA Creditable Amt. Adj.

9b Total RUIA Maximum Benefit Amt. Adj.

12a Total RRA Tier I Adj.

12b Total RRA Tier II Adj.

12c Total RRA Miscellaneous Adj.

12d Total RRA Sick Pay Adj.

16. ADJUSTMENT OUTSIDE OF THE STATUTE OF LIMITATIONS

Public Law Board Award ____________________

Settlement Allocation ____________________

Wage Continuation Plan ____________________

Railroad Retirement Board Request ____________________________________________________

Other Pay for Time Lost Allocation __________________

Specify Type: _________________________________________________________________________

Other __________________

Specify Type: _______________________________________________________________

Form BA-4 (01-12) PRIOR EDITIONS ARE OBSOLETE