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2 

7 

United States of America Form Approved 

Railroad Retirement Board OMB No. 3220-0089 

Employer's Supplemental
 

Pension Report
 

Railroad Contact Official's Name and Address 

, 

Fax Number: 

SECTION 1 - IDENTIFYING INFORMATION 

1 Social Security Number 

3 Name 

4 Date Released 

6 Job Title or Category 

Salaried 

Non-Agreement 

Agreement (Union) 

Other 

5 BA 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 provides information about supplemental annuities and how they are affected by railroad pensions. 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 5, 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’S PENSION ENTITLEMENT 

Was the employee covered under either a Yes – Go to Section 4 

defined benefit pension plan or money 

purchase pension plan with your railroad? No – Go to Section 6 

SECTION 4 – EMPLOYEE’S PENSION BENEFIT INFORMATION 

8 Enter the name of the pension plan. 

9 How is the plan funded? 

10	 Is the monthly pension reduced by the 

amount of the RRB supplemental annuity? 

11 a	 Is the employee currently eligible for the 

pension? 

b Select which applied to the employee. 

12	 Indicate the type of pension payment. 

13 Monthly Pension Information 

a	 Enter the date the employee began, 

or will begin, receiving the monthly 

pension. If the date is unknown, 

enter an estimated date. 

Month Day Year 

b Is the amount of the monthly pension 

based on the employer’s contributions 

greater than $43.00? 

Yes – Go to Section 6 

No 

Employer contributions only – Go to Item 10 

Both employer and employee contributions – Go to Item 10 

Employee contributions only – Go to Section 6 

Yes it is reduced 

by all of the supplemental annuity - Go to Section 6 

by part of the supplemental annuity - Enter percentage: % 

No it is not reduced 

Yes – Go to Item 11b 

No – Go to Section 6 (IMPORTANT: Notify the RRB when the employee 

becomes eligible for or begins receiving the pension.) 

Filed for the pension – Go to Item 12 

Elected to defer distribution from the pension account – Go to Item 14 

Monthly pension – Go to Item 13 

Lump sum elected in lieu of a monthly pension – Go to Item 14 

Lump sum paid under the plan’s small benefit provision – Go to Item 15 

c	 Enter the amount of the monthly 

pension based on the employer’s 

contributions then go to Section 6. 

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14 Lump Sum Elected In Lieu of a Monthly Pension or Deferred Distribution 

a	 Enter the date the employee would 

have begun receiving the monthly 

pension if the lump sum had not 

been elected. 

Month Day Year 

b Would the amount of the monthly 

pension based on the employer’s 

contributions have been greater than 

$43.00? 

Yes – Go to Section 6 

No 

15 Lump Sum Paid Under Plan’s Small Benefit Provision 

a Enter the date the lump sum was 

paid. 

b Enter the total amount of the lump sum. 

Month Day Year 

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SECTION 5 – REMARKS 

c	 Enter the amount of the monthly 

pension based on the employer’s 

contributions then go to Section 6. 

c	 Enter the amount of the lump sum 

based on the employer’s 

contributions. 

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 6 – 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	 Title 

Business Telephone Number (_____)_______________ Date 

Return this form to:	 US Railroad Retirement Board 

844 N. Rush Street, RSBD-RIS 

Chicago, IL 60611-1275 

Fax Number: (312) 751-7192 

DO NOT WRITE IN THIS AREA -- FOR RRB USE ONLY 

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 Associate Chief Information 

Officer for Policy and Compliance, US Railroad Retirement Board, 844 N. Rush St, Chicago, Illinois 60611-1275. 

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