FORM APPROVED
UNITED STATES OF AMERICA
O.M.B. NO. 3220-0012
RAILROAD RETIREMENT BOARD
EMPLOYER NUMBER
CALENDAR QUARTER AND YEAR
EMPLOYER’S QUARTERLY REPORT OF CONTRIBUTIONS
UNDER THE RAILROAD UNEMPLOYMENT INSURANCE ACT
This Report is Required By Law - 20 C.F.R. 345.116
NAME AND ADDRESS OF EMPLOYER
Check appropriate box for report status / method of payment
Final Report
Check/Money Order
Electronic
All employers must return original Form DC-1 to:
CHIEF FINANCIAL OFFICER
U.S. RAILROAD RETIREMENT BOARD
844 N Rush Street, Chicago, Illinois 60611-2092
READ THE INSTRUCTIONS ON THE REVERSE SIDE OF THIS FORM BEFORE PREPARING THIS REPORT
MONTH
CONTRIBU-
AMOUNT OF COMPENSATION
AMOUNT OF CONTRIBUTION
BA-4
YEAR
TION
DUE (COL. (c) x COL. (d))
PREPARED
ADJUSTED
SUBJECT TO CONTRIBUTION
RATE
(e)
(c)
(a)
( b)
(d)
1. CURRENT REPORTING
0.00%
$0.00
PERIOD
2.
0.00%
$0.00
Compensation Adjustments
reported on Form BA-4.
0.00%
$0.00
ATTENTION: Attach
a
0.00%
$0.00
statement of explanation to
your fourth quarter Form
0.00%
$0.00
DC-1 if the item 3 total
compensation reported on
0.00%
$0.00
Forms DC-1 for the four
quarters of this calendar
0.00%
$0.00
year does not agree with
compensation reported on
0.00%
$0.00
Form
Ba-3a
and
any
adjustments of Form BA-4.
0.00%
$0.00
0.00%
$0.00
0.00%
$0.00
0.00%
$0.00
0.00%
$0.00
$0.00
$0.00
3. Total
4.
0.00%
$0.00
1.
Corrections to prior
0.00%
Form DC-1 (indicate
$0.00
2.
quarter and year)
$0.00
3.
$0.00
$0.00
5. Total
6a.
6b.
7.
$0.00
Interest/Penalties (I/P) (Indicate Quarter/Year)
I/P Total
Report Total
8.
AMOUNT OF REMITTANCE
Check or money order should be made p
ayable to the U.S. Railroad Retirement Board
For Railroad Retirement Board (RRB) Use Only:
9.
PREPARER’S NAME (Print)
TELEPHONE NO.
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 LAW AND REGULATIONS APPLICABLE
HERETO.
I UNDERST
AND 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
TITLE
(OFFICER AS PER INSTRUCTION ON REVERSE)
DATE
FORM DC-1 (4-03) DESTROY PRIOR EDITIONS
(OVER)
1
2
