G-440, Report Specification Sheet (proposed)

FORM APPROVED
OMB NO. 3220-XXXX

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

REPORT SPECIFICATIONS SHEET

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RETURN TO:
(Address on reverse side of reporting form)
U.S. RAILROAD RETIREMENT BOARD
844 NORTH RUSH STREET
CHICAGO, IL 60611-2092

IMPORTANTNOTE:
This form must be completed and submitted with reports of
information required by law under Section 9 of the Railroad
Retirement act (RRA) and Section 6 of the Railroad
Unemployment InsuranceAct (RUIA) for the purpose of paying
RRA and RUIA benefits.

1 CORPORATE NAME AND ADDRESS OF EMPLOYER

3 DATE REPORT BEING S U B M I ~ E D 4 EMPLOYER BA NUMBER
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2 OTHER EMPLOYER NAME. IF ANY

PERSON TO CONTACT REGARDING THIS REPORT

8 FACSIMILE NUMBER

7 TELEPHONE NUMBER

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IAM NOT SUBMllTlNG AN ANNUAL REPORT BECAUSE MY COMPANY HAS NO EMPLOYEES b (GOt o Certification Statement at bottom)

IAM NOT SUBMriTlNG A GROSS EARNINGS REPORT BECAUSE MY COMPANY HAS NO EMPLOYEES WITH A SOCW. SECURITY
NUMBER ENDING IN "30."

10 W E OF REPORT (CHECK ONLY ONE)

11 REPORT MEDIUM (CHECK ONLY ONE)
MAGNETIC TAPE CARTRIDGE

ANNUAL REPORT (FORM BA-3); REPORT INCLUDES:
(Check ALL that apply)
Regular Compensationand Service
Sick Pay and Miscellaneous Compensation
Employee Addresses
ADJUSTMENT REPORT (FORM BA-4); REPORT INCLUDES:
(Check ALL that apply)

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CD-ROM or 3%" DISKETTE

FfP (File Transfer Protocol) INTERCHANGE
SECURE E-MAIL

NOTE: Report Record Lengths:
Form BA-3 = 300 Form BA-4 = 200

Regular Compensationand Service
Sick Pay and Miscellaneous

17

SEPARATION ALLOWANCWSEVERANCE PAY REPORT (FORM BA-9)

12 (A) LABEL USED (CHECK ONLY ONE):

NONE

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PAPER Go to Item 13.

GROSS EARNINGS REPORT (FORM BA-I I )
ADDRESS REPORT (FORM BA-GA)
STANDARD IBM

NONSTANDARD HEADERITRAILER

LEADING TAPE MARK

(B) FILE NAME:

(C) REEL NUMBER@)
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IF YOUR COMPANY IS REPORTING FOR A SUBSIDIARYCOMPANY(S1. LIST ALL EMPLOYER NUMBERS. ATTACH A SEPARATE SHEET IF NECESSARY.

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14 1 understand that civil and criminal penalties can be imposed against me for false or fraudulent statements or for withholding information
to misrepresent a fact material to determining a right to payment under the Railroad Retirement Act or the Railroad Unemployment
Insurance Act. I certify that, to the best of my knowledge, the informationwhich I have given is true, complete, and correct.
SIGNATURE OF CERTIFYING OFFICERIDATE

REMARKS

Form G-440 (Not Approved For Use

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RECAPITULATION SHEET
NOTE: I f more than 15 pages per report, photocopy this page before using.
Recapitulatlon Sheet Instructions
ltem 1. Check only one box per report.
ltem 2. Report Page # Enter the page number shown in ltem 4 on Form BA-3 or ltem 3 on Form BA-4 that you are recapping. NOTE: 15 pages from one report can be recapped
on a single Recapitulation Sheet.
ltem 3. Report Record Count Enter the total number of lines shown in ltem 13 on Form BA-3 or ltem 14 on Form BA-4 for each page YOU are recapping.
NOTE: For Items 4, 5, and 6, below, enclose negative amounts in parentheses, i.e., "(10,000.00)".
ltem 4. Net Compensation Totals Enter the totals shown in ltem 14 on Form BA-3 or ltem 15 on Form BA-4 for each page you are recapping.
ltem 5. Recap Sheet Page Totals - Summarize the record counts from ltem 3 and the compensation amounts from ltem 4a-f of this sheet and enter the totals in the respective
columns.
ltem 6. Recap Sheet Grand Totals Single page recapitulationsheet Enter the totals from ltem 5, below.
Multi-page recapitulationsheet Summarize ltem 5 from each sheet and then enter sum total.
BA-3,
Annual
Report
Form BA-4, Adjustment Report
Form
I.
Check One:
3.
4. NET COMPENSATIONTOTALS
2.
RRA COMPENSATION
RUlA COMPENSATION
REPORT
REPORT
f.
8.
d.
c.
b.
RECORD a.
PAGE
MISCELLANEOUS
QUALIFYING
MAXIMUM
BENEFIT
SICK PAY
TIER I
TIER II
COUNT
#
COMPENSATIQN
AMOUNT
AMOUNT

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1 rAP)

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71)

12)
13)

n4)
B)
5. Recap Sheet
Page Totals

6. Recap Shed
Grand Totals
We estimate this form takes from l5
to 75 minutes per response, including the time for reviewing instructions, getting the needed data and reviewing the completed form. ~
~agencies
d may~not ~
l sponsors and respondents
or
are not required to respond to a
Of Information unless it displays a valid OMB number. If you wlsh, send comments regarding the accuracy of our
or any other aspect ofthis form, including suggestions for
to
OF INFORMATIONRESOURCES MANAGEMENT. RAILROAD RETIREMENT BOARD, 844 N. RUSH STREET, CHICAGO, IL 60611-2092.

Form G-440 (Not Approved For Use)