Form Dc-1 - Employer'S Quarterly Report Of Contributions Under The Railroad Unemployment Insurance Act

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FORM APPROVED
UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD
O.M.B. NO. 3220-0012
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
o
o
o
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
( c)
(e)
(a)
( b )
(d )
1. CURRENT REPORTING
PERIOD
2.
Compensation Adjustments
reported on Form BA-4.
ATTENTION:
attach
a
statement of explanation to
your fourth quarter Form
DC-1 if the item 3 total
compensation reported on
Forms DC-1 for the four
quarters of this calendar
year does not agree with
compensation reported on
Form
Ba-3a
and
any
adjustments of Form BA-4.
3. Total
4.
1.
Corrections to prior
Form DC-1 (indicate
2.
quarter and year)
3.
5. Total
6a.
6b.
7.
Interest/Penalties (I/P) (Indicate Quarter/Year)
I/P Total
Report Total
8.
AMOUNT OF REMITTANCE Check or money order should be made payable to the U.S. Railroad Retirement Board
For Railroad Retirement Board (RRB) Use Only:
9.
PREPARER’S NAME (Print)
TELEPHONE NO. (
)
PENALTY:
Railroad Unemployment Insurance Act: Section 9(a) provides a fine up to $10,000 or imprisonment up to one year, or
both, for a false or fraudulent statement or report, or willfully failing or refusing to make any report or furnish information
required by the RRB in the administration of this Act.
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. AND CONTAINED IN EACH SCHEDULE OR STATEMENT ATTACHED AND MADE PART
HEREOF, ARE TRUE, CORRECT, AND IN ACCORDANCE WITH THE LAWS AND REGULATIONS APPLICABLE THERETO.
SIGNATURE
TITLE
(OFFICER AS PER INSTRUCTION ON REVERSE)
DATE
FORM DC-1 (4-00) DESTROY PRIOR EDITIONS
(OVER)

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