United States of America 

Railroad Retirement Board 

Form Approved 

OMB No. 3220-0089 

REQUEST FOR INFORMATION ABOUT 

NEW OR REVISED 

EMPLOYER PENSION PLAN 

DO NOT WRITE IN THIS AREA - FOR RRB USE ONLY 

Date Received at RRB Received by 

1. Railroad Contact Official's Name and Address 

Facsimile No.: 

2. BA No. 

3. Date RRB Released Form to Railroad 

SECTION 1 INSTRUCTIONS 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. Also read the “Important Notices” below. Type or print legibly in ink. If you need more space than is provided, 

use Section 4, 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. 

This form is used to obtain information about a private railroad pension plan to determine if benefits from the plan will 

cause a reduction in the supplemental annuities of covered employees. Submit a copy of the plan or a summary plan 

description with the completed form. Complete a separate form for each plan submitted. 

Return the completed form to the US Railroad Retirement Board, 844 N. Rush Street, P&S-CESC, Chicago, IL 60611-1275 

or fax to (312) 751-7123. 

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 of Policy and Compliance, US Railroad Retirement Board, 844 N. Rush St., 

Chicago, Illinois 60611-1275. 

SECTION 2 VERIFICATION OF PENSION PLAN 

4. Does your organization maintain a private pension plan 

for any group of current or former employees? 

Yes 

No – Go to Section 5 

SECTION 3 INFORMATION ABOUT THE PLAN 

5. Enter the name of the plan. 

6. Indicate the type of plan. Defined benefit plan 

Money purchase plan 

7. Indicate how the plan is funded. 

Employer contributions only 

Both employer and employee contributions 

Employee contributions only – Go to Section 5 

G-88r (03-21) 
8. Indicate the group(s) of employees 

covered by the plan. 

All 

Salaried 

Non-agreement (hourly wage - not covered by collective bargaining 

agreement) 

Agreement (if only members of certain collective bargaining units are 

covered by the plan, list the bargaining units in Remarks) 

Other (explain in Remarks) 

9. Indicate if the monthly benefit is reduced 

by all or part of the supplemental annuity. 

Yes it is reduced 

by all of the supplemental annuity - Go to Section 5 

by part of the supplemental annuity - Enter percentage: % 

Not reduced by the supplemental annuity 

10. Indicate if the pension is reduced by a 

portion of the actual or estimated regular 

railroad retirement annuity (Tier 1, Tier 2 

and Vested Dual Benefit). 

Yes it is reduced – Enter percentage: % 

No it is not reduced 

11. Indicate the status of the plan. 

New plan 

Old plan previously not reported to RRB 

Amended plan previously reported to RRB 

Amended plan previously not reported to RRB 

Closed plan - Enter date closed to new employees: _ 

12a. Enter the effective 

date of the plan. 

Month Day Year 12b. Enter the latest revision 

date of the plan, if 

different. 

Month Day Year 

 

13. Has the plan been approved by the Internal Revenue 

Service? 

Yes - Attach a copy of the IRS letter approving the plan. 

No - Submit a copy of the IRS letter approving the plan 

when received. 

SECTION 4 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 5 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 RR Contact Official Date 

 ( ) 

Title Business Telephone Number 

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