Fillable DESIGNATION OF CONTACT OFFICIALS (Railroad Retirement Board)

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DESIGNATION OF CONTACT OFFICIALS (Railroad Retirement Board)

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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
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) S
ervice 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) R
ailroad 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) R
RA Annuity Estimate - Receives reports of annuity estimates for employees with 120 or more service months.
(5) S
ection 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) S
ection 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) T
ier 1 Tax Report - RUIA - Receives notices of Tier 1 taxes due on RUIA sickness benefits creditable as Tier 1 compensation (Form
ID-6).
(8) P
repayment 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) R
ailroad Hiring - Handles matters pertaining to the employee placement program under the RUIA.
(10) D
isability - Handles Form G-251 requests for job duties.
(11) S
treet Address - If contact official address is P.O. Box, enter primary railroad street address.
(12) E
nter 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.
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DESIGNATION OF CONTACT OFFICIALS (Railroad Retirement Board)

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Completed 11 August 2020

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