G-88r.1 Request for Additional Information About Employer Status

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0089

REQUEST FOR ADDITIONAL INFORMATION ABOUT EMPLOYER PENSION PLAN IN
CASE OF CHANGE OF EMPLOYER STATUS OR TERMINATION OF PENSION PLAN
INSTRUCTIONS: The Railroad Retirement Board (RRB) requests you to complete this form for the pension plan
named in ltem 4. Please read "Important Notices" on the next page and complete Section 1 through Section 5.
1. Railroad Contact Official's Name and Address

2.

BA No.

!
Date RRB Released Form to Railroad

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Facsimile No.:

SECTION 1 - RAILROAD PENSION CURRENTLY IN RRB RECORDS
If you have a pension plan effective later than the pension plan in ltems 4-6, line out the RRB entries and enter the
current information in ltems 4-6.

+

4.

Name of pension plan.

5.

Effective date of pension plan named in
Item 4.

6. Employee groups covered by pension
plan named in ltem 4.

+
+

-

SECTION 2 SALE, MERGER, REORGANIZATION OR TERMINATION
OF COVERAGE UNDER THE RAILROAD RETIREMENT ACT
7. Enter an "X in the appropriate box:
The employees described in ltem 6 are now automatically covered
by another pension plan (other than benefits under the Railroad
Retirement Act (RRA)) as of the date the employer has been sold,
has merged, has reorganized, or is no longer covered under the
RRA.

YES - Go to ltem 8

+

NO - Go to Section 3
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8.

Enter the name of the pension plan
described in ltem 7.
(Attach a copy of the plan or a summary
plan description.)

9.

Enter the Railroad Contact Official's
address for the pension plan described in
ltem 7.

+

SECTION 3 -TERMINATION OF PENSION PLAN NAMED IN ITEM 4
10. Enter an " X in the appropriate box:
YES-Gotoltemll
The employees described in ltem 6 have been given the option in a written
3
plan or agreement of either a monthly annuity purchased from an insurance
NO - GO to Item 12
company or a lump-sum payment.
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11. Enter the name and address of the
insurance company assuming
responsibility for this pension plan.

3

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1

12. Enter an " X in the appropriate box:

YES

The Pension Benefit Guaranty Corporation will assume responsibility for the
pension plan named in ltem 4.

-

SECTION 4 REMARKS
You may use this section to enter any additional information that you feel may be important to include.

-

SECTION 5 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 RR Contact Official
Business Telephone Number (Include Area code)
Please return this form to:

Title
(

)

Date

U.S. Railroad Retirement Board
A&T-QRSC
844 N Rush Street
Chicago, IL 6061 1-2092
Facsimile No.: (312) 751-7190
IMPORTANT NOTICES

PAPERWORK REDUCTION ACT NOTICE
The information requested on this form is needed to determine if a reduction to the supplemental annuities of your retired employees is
required 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 7 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 Chief of Information Resources
Management, Railroad Retirement Board, 844 N. Rush St, Chicago, Illinois 60611-2092.
Date Reply Received at RRB

DO NOT WRITE IN THIS AREA -- FOR RRB USE ONLY
Received By:

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G-88r.l (03-03)