G-88p (04-12) Employer's Supplemental Pension Report

CURRENT

United States of America
Railroad Retirement Board

Employer's Supplemental
Pension Report
2

Railroad Contact Official's Name and Address

Form Approved
OMB No. 3220-0089

SECTION 1 - IDENTIFYING INFORMATION
1 Social Security Number
3 Name
4 Date Released

5 BA Number

,
6 Job Title or Category
Salaried
Non-Agreement
Agreement (Union)
Other

Fax Number:

SECTION 2 – GENERAL INFORMATION FOR THE EMPLOYER
For assistance in completing this form, read Part VI, Chapter 6, of the Employer Reporting Instructions located on our website at
www.rrb.gov, which provide information about supplemental annuities and how they are affected by railroad pensions and 401(k)
distributions. Also read the “Important Notices” on the next page. Type or print legibly in ink. If you need more space than is
provided, use Section 6, Remarks. Based on your answer to a question, you may be told to “Go to” another item. If no “Go to”
instructions are given, answer the next item in order. Do not skip any items unless directed to do so.
SECTION 3 – EMPLOYEE BENEFIT ENTITLEMENT
7

Select the type of benefit to which employee is, or will be,
entitled. If employee elected a lump sum payment in lieu of a
monthly pension benefit, check “monthly pension benefit”.

Monthly pension benefit – Go to Section 4
Distribution from a 401(k) Savings Plan – Go to Section 5
None of the above – Go to Section 7

SECTION 4 – EMPLOYEE ENTITLED TO MONTHLY PENSION BENEFIT

8

Enter the name of the pension plan.

9

How is the plan funded?

10

Employer contributions only – Go to Item 10
Both employer and employee contributions – Go to Item 10
Employee contributions only – Go to Section 7

Indicate if the monthly benefit is reduced,
and if so, by all or part of the supplemental
annuity.

Yes it is reduced
by all of the supplemental annuity - Go to Section 7
by part of the supplemental annuity - Enter percentage:
No it is not reduced

%

11

Has the employee filed for the pension
benefit?

Yes – Go to Item 12
No – Go to Section 7 (IMPORTANT: Retain a copy of this form. Complete
and submit it when the employee files for the pension benefit.)

12

Indicate the type of benefit payment.

Monthly benefit – Go to Item 13
Lump sum in lieu of a monthly benefit – Go to Item 14a
Lump sum due to the plan’s small benefit provision – Go to Section 5

13

Enter the date the employee began,
or will begin, receiving a monthly
pension. If the date is unknown,
enter an estimated date.
Month

15

Day

Year

14a If a lump sum was paid in lieu of a
14b Enter the date the lump sum was
monthly benefit, enter the date the
paid.
monthly benefit would have begun if the
lump sum had not been elected.
Month
Day
Year
Month
Day
Year

Is the amount of the monthly pension that is based on the
employer’s contributions greater than $43.00?

Yes – Go to Section 7
No – Enter the amount of the monthly benefit based on the
employer’s contributions: ___
____

G-88p (04-12)

SECTION 5 – EMPLOYEE ENTITLED TO DISTRIBUTION FROM 401(k) SAVINGS PLAN
(Complete Items 18a through 19b if the employee was paid a lump sum due to a small benefit provision.)
16

Enter the name of the 401(k) Plan

17

Is the employer obligated by the plan to make the
contributions to the employee’s account regardless of
profit?

18

a Has the employee
filed for the
distribution?

19

a Enter the total amount of the distribution.

Yes – Go to Item 18a
No – Go to Section 7

18b Enter the date the distribution was paid.
Yes – Go to Item 18b 
No – Go to Section 7 (IMPORTANT: Retain a copy
Month
Day
Year
of this form. Complete and submit the form when
the employee files for the distribution.)

b Enter the amount of the distribution attributable to the employer’s contributions.
SECTION 6 – REMARKS
You may use this section to enter any additional information that you feel may be important to include. Be sure to include the item
number of any answer you wish to continue.

SECTION 7 – 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 Railroad Contact Official
Business Telephone Number

(_____)_______________

_____________________________________________
Title
Date
DO NOT WRITE IN THIS AREA -- FOR RRB USE ONLY

Return this form to:

US Railroad Retirement Board
844 N. Rush Street, RBD-RIS
Chicago, IL 60611-2092
Fax Number: (312) 751-7192

Date Reply Received at RRB
Received By

IMPORTANT NOTICES
PAPERWORK REDUCTION ACT NOTICE
The information requested on this form is needed to determine if a reduction is required to the supplemental annuities of your retired
employees 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 8 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, US Railroad Retirement Board, 844 N. Rush St, Chicago, Illinois 60611-2092.

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G-88p (04-12)