Form G-117a (10-13) 

DESIGNATION OF CONTACT OFFICIALS

(See Instructions for Completing and Mailing This Form on Reverse Side)

EMPLOYER NAME 

EMPLOYER BA NUMBER DATE

(1) EXECUTIVE OFFICER (2) SERVICE AND COMPENSATION

NAME NAME 

TITLE TITLE 

STREET ADDRESS STREET ADDRESS 

CITY, STATE & ZIP CODE CITY, STATE & ZIP CODE 

TEL NO. E-MAIL ADDRESS TEL NO. E-MAIL ADDRESS

FAX NO. FAX NO.

(3) RAILROAD RETIREMENT AWARDS (4) RRA ANNUITY ESTIMATE 

NAME NAME 

TITLE TITLE 

STREET ADDRESS STREET ADDRESS 

CITY, STATE & ZIP CODE CITY, STATE & ZIP CODE 

TEL NO. E-MAIL ADDRESS TEL NO. E-MAIL ADDRESS 

FAX NO. FAX NO.

(5) SECTION 2(F) - RUIA (6) SECTION 12(O) - RUIA

NAME NAME 

TITLE TITLE 

STREET ADDRESS STREET ADDRESS 

CITY, STATE & ZIP CODE CITY, STATE & ZIP CODE 

TEL NO. E-MAIL ADDRESS TEL NO. E-MAIL ADDRESS 

FAX NO. FAX NO.

(7) TIER 1 TAX REPORT - RUIA (8) PREPAYMENT CLAIMS VERIFICATION - RUIA

NAME NAME 

TITLE TITLE 

STREET ADDRESS STREET ADDRESS 

CITY, STATE & ZIP CODE CITY, STATE & ZIP CODE 

TEL NO. E-MAIL ADDRESS TEL NO. E-MAIL ADDRESS 

FAX NO. FAX NO.

Form Approved 

OMB No. 3220-0200

United States of America 

Railroad Retirement Board
Form G-117a (10-13) 

(9) RAILROAD HIRING (10) DISABILITY

NAME NAME 

TITLE TITLE 

STREET ADDRESS STREET ADDRESS 

CITY, STATE & ZIP CODE CITY, STATE & ZIP CODE 

TEL NO. E-MAIL ADDRESS TEL NO. E-MAIL ADDRESS

FAX NO. FAX NO.

(11) STREET ADDRESS 

The above officials of this employer are authorized to serve in the capacities indicated.

(12) SIGNATURE PRINT NAME TITLE DATE

INSTRUCTIONS

The information requested on this form is used to both establish a Railroad Retirement Board (RRB) contact official for the items described 

below and to change a contact official or an official's address. One contact official may be designated to serve in all capacities. If one contact 

official is designated to serve in all capacities, complete box one and write "same" in all other boxes. Please notify the RRB immediately of any 

change in official or address. Include, on an attachment, the names of subsidiary or affiliated companies for which the above designated 

contact officials are authorized to act and any other information related to the designations. If different contact officials are to be designated for 

subsidiary or affiliated companies, use a separate Form G-117a. Please execute and return promptly to the Railroad Retirement Board, Office 

of Programs, P&S, Compensation and Employer Services Center, 844 North Rush Street, Chicago, Illinois 60611-1275. 

Items Contact Official and/or Description 

(1) Executive Officer - Executive of the organization to whom all general correspondence should be addressed with respect to 

administration of RRA and RUIA. 

(2) Service and Compensation - Responsible for submitting service and compensation reports, including Forms BA-3, BA-4, BA-6A, 

BA-9, BA-11, and DC-1. Handles correspondence and other matters related to service and compensation reporting, and RUIA tax 

contributions, including Forms AA-12, G-88A.1, G-88A.2, GL-4, GL-4A, GL-4B, GL-24, GL-77A, GL-99, GL-129, GL-130, GL-131, 

GL-132, ID-40Q, ID-40R/S, and UI-41A. 

(3) Railroad Retirement Awards - May receive notices of RRA annuity awards. Also handles correspondence related to annuity awards, 

including Forms G-73A.1, RL-13G, RL-27, and G-88P. 

(4) RRA Annuity Estimate - Receives reports of annuity estimates for employees with 120 or more service months. 

(5) Section 2(f) - RUIA - Receives and submits notices related to the reimbursement of RUIA benefits under Section 2(f) of the RUIA, 

including Forms ID-30 and ID-3U. 

(6) Section 12(o) - RUIA - Receives notices of lien under Section 12(o) of RUIA and handles various types of correspondence related to 

Section 12(o), including Forms ID-30B and ID-3S. 

(7) Tier 1 Tax Report - RUIA - Receives notices of Tier 1 taxes due on RUIA sickness benefits creditable as Tier 1 compensation (Form 

ID-6). 

(8) Prepayment Claims Verification - RUIA - Receives notices of applications and claims filed under the RUIA (Form ID-4K) and notices 

of RUIA claim determinations (Form ID-4E). 

(9) Railroad Hiring - Handles matters pertaining to the employee placement program under the RUIA. 

(10) Disability - Handles Form G-251 requests for job duties. 

(11) Street Address - If contact official address is P.O. Box, enter primary railroad street address. 

(12) Enter your signature, title, and the date signed.

PAPERWORK REDUCTION ACT/PRIVACY ACT NOTICES

The Railroad Retirement Board (RRB) is authorized to collect the information requested on this form under Section 7(b)6 of the Railroad 

Retirement Act of 1974 and Section 5(b) of the Railroad Unemployment Insurance Act. Although you are not required to provide the requested 

information, cooperation in doing so will assist the RRB in providing information to employers to meet their fiscal and regulatory obligations 

toward benefit programs as well as support the RRB administration of those programs. 

We estimate this form takes an average of 15 minutes per response to complete, including the time needed 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 the completion time, to: the Associate Chief Information Officer of 

Policy and Compliance, Railroad Retirement Board, 844 N. Rush Street, Chicago, IL 60611-1275.