Rail Employer Reporting Instructions

Appendix II: Pay for Time Lost Worksheet

Section 1: Identifying Information

Employee’s Name: _________________________SSN: __________________________

Section 2: Service Month Allocation

The allocation must relate to the actual period of absence from service due to the injury.

A. Date of Injury: ___________ B. Reported Service Months to Date: ___________ (Exclude Deemed Service Months in or after the year of Injury)

C. Service Months needed to attain: 120_______ 240_______ 360_______

D. Service Month Allocation:

 Year Allocated Months Total

______ J F M A M J J A S O N D _______

______ J F M A M J J A S O N D _______

______ J F M A M J J A S O N D _______

______ J F M A M J J A S O N D _______

______ J F M A M J J A S O N D _______

______ J F M A M J J A S O N D _______

 E. Total Allocated Service Months: _______

 F. Service Months to Date: +_______ (2B)

 G. Projected Total Service Months: = _______

Section 3: Minimum Creditable Compensation Calculation

The monthly compensation allocation must be at least ten times the employee’s daily pay 

rate in effect on the first day to which Pay for Time Lost payments relate.

A. Employee’s Daily Pay Rate: _______ 

B. Minimum Monthly Compensation: Employee Daily Pay Rate__________ x 10 = ___________ 

 (3A)

C. Total Allocated Compensation:

Minimum Monthly Compensation __________ x Total Allocated Service Months__________ = _____________ 

 (3B) (2E)
For a general overview of the topic, see Form IB-4, “Pay for Time Lost from Regular Railroad Employment”.

Section 4: Railroad Retirement Tax Act Calculation

Pay for Time Lost compensation is subject to the Tier I, Tier II and Medicare tax rates in 

effect when the payment is made. Annual maximum earnings bases apply to Tier I and 

Tier II taxes.

Employer Tax Calculation:

Tier I Taxable Compensation ___________ x___________ % = ___________ Tier I Tax

Medicare Taxable Compensation________ x_________ % = ___________ Medicare Tax

Tier II Taxable Compensation __________ x___________ % = ___________ Tier II Tax

Total Employer Tax ___________

Employee Tax Calculation:

Tier I Taxable Compensation ___________ x___________ % = ___________ Tier I Tax

Medicare Taxable Compensation________ x_________ % = ___________ Medicare Tax

Tier II Taxable Compensation __________ x___________ % = ___________ Tier II Tax

 

Total Employee Tax ___________ 

Section 5: Railroad Unemployment Insurance Act Employer Contributions

RUIA contributions are calculated using the rates and monthly limits in effect during the 

months the Pay for Time Lost payments relate. RUIA creditable compensation is 

calculated by multiplying the service months allocated to the year by the lesser of the 

applicable RUIA monthly maximum or the employee’s allocated monthly compensation.

RUIA Creditable Contribution RUIA 

Year Compensation x Rate = Contribution

_____ ______________ x ________ = ____________

_____ ______________ x ________ = ____________

_____ ______________ x ________ = ____________

_____ ______________ x ________ = ____________

_____ ______________ x ________ = ____________

_____ ______________ x ________ = ____________

 Total Employer RUIA Contribution ____________