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The information contained in this report (see Attachment D), which is
required by law under Section 9 of the Railroad Retirement Act (RRA) and
Section 6 of the Railroad Unemployment Insurance Act (RUIA) and is
authorized for collection under OMB control number 3220-0173, is needed
for two purposes: to establish eligibility for an additional lump-sum
amount under the RRA and to establish a disqualification period under
the RUIA. Failure to report or the making of a false or fraudulent
report can result in criminal prosecution or civil penalties, or both.
We estimate the electronic version of this form, transmitted by
e-mail or FTP, takes an average of 1 hour and 16 minutes per response to complete,
including time for reviewing the instructions, getting the needed data,
and reviewing the completed form.
This exhibit explains only magnetic media format. For information about
the data to be entered, refer to Part
V, Chapter 6.
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1 |
"L". |
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2-5 |
Four digit applicable tax year being reported. |
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6 |
Code "4" for an initial report or an increase adjustment. Code
"M" for a decrease adjustment. |
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7-10 |
Four-digit employer number assigned by the Railroad Retirement
Board. |
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11-19 |
Employee's social security number. |
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20-39 |
First twenty (20) characters of the employee's surname. Spaces
in such names as McCarthy, St. Clair, De La Cross are
acceptable. |
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40-54 |
First fifteen (15) characters of the employee's first name. |
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55 |
Employee’s middle initial. |
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56 |
Blank Filler. |
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57-64 |
An eight-digit separation allowance amount. Do not use a decimal
place. The format is $$$$$$cc. For adjustments, enter the net
increase amount to be applied to the initial report. Do not sign
the field. Zeros should be used to fill the left most positions,
if necessary. |
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65 |
Code 1 for an initial report.
Code 2 for an adjustment report.
Code 3 for a periodic payment - not the final payment.
Code 4 for a periodic payment - final payment. |
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66-73 |
Date employee relinquished employment rights. Format is MMDDCCYY. |
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74 |
Blank Filler. |
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75-82 |
Eight-digit compensation amount. Do not use a decimal place.
Format is ($$$$$$cc). Do not sign the field. Zeros should be
used to fill the left most positions if necessary. Field may be
left blank. |
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83-86 |
Four digit applicable creditable year being reported. |
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87-92 |
Total gross amount of separation in whole dollars, $$$$$$. Use
zero to fill the left most positions as needed. |
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93 |
Blank Filler. |
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94-100 |
Show the last rate of pay. Format includes a floating decimal
place to account for hourly through monthly rates. For example,
9.99999, 99.9999, 999.999 etc. |
|
101 |
The code corresponding to the period to which the rate applies,
as follows:
Code 1 = per hour;
Code 2 = per day/100 (or 150) miles;
Code 3 = per week; and
Code 4 = per month. |
|
102 |
The code corresponding to the employee's normal work week, as
follows:
Code 5 = five-day week;
Code 6 = six-day week;
Code 7 = seven-day week;
Code 8 = train and engine service; and
Code 9 = dining car and Pullman service. |
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103-120 |
Blank Filler. |
Paperwork Reduction Act (PRA) Notice
Federal agencies may not conduct or sponsor, and respondents are not required to
respond to, any collection of information unless it displays a valid OMB number.
If you wish, send comments regarding the accuracy of our estimates or any other
aspect of these forms, including suggestions for reducing completion time, to
Chief of Information Services
U.S. Railroad Retirement Board
844 North Rush Street, 4th floor
Chicago, IL 60611-2092
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.
We recommend using the latest version.
