Section 1: Identifying Information
Employee’s Name: _________________________SSN: __________________________
Section 2: Service Month Allocation
The allocation must relate to the actual period of absence from service due to the injury.
A. Date of Injury: ___________ B. Reported Service Months to Date: ___________
(Exclude Deemed Service Months in or after the year of Injury)
C. Service Months needed to attain: 120_______ 240_______ 360_______
D. Service Month Allocation:
Year Allocated Months Total
______ J F M A M J J A S O N D _______
______ J F M A M J J A S O N D _______
______ J F M A M J J A S O N D _______
______ J F M A M J J A S O N D _______
______ J F M A M J J A S O N D _______
______ J F M A M J J A S O N D _______
E. Total Allocated Service Months: _______
F. Service Months to Date: +_______
(2B)
G. Projected Total Service Months: = _______
Section 3: Minimum Creditable Compensation Calculation
The monthly compensation allocation must be at least ten times the employee’s daily pay rate in effect on the first day to which Pay for Time Lost payments relate.
A. Employee’s Daily Pay Rate: _______
B. Minimum Monthly Compensation:
Employee Daily Pay Rate__________ x 10 = ___________
(3A)
C. Total Allocated Compensation:
Minimum Monthly Compensation __________ x Total Allocated Service Months__________ = _____________
(3B) (2E)
Section 4: Railroad Retirement Tax Act Calculation
Pay for Time Lost compensation is subject to the Tier I, Tier II and Medicare tax rates in effect when the payment is made. Annual maximum earnings bases apply to Tier I and Tier II taxes.
Employer Tax Calculation:
Tier I Taxable Compensation ___________ x___________ % = ___________ Tier I Tax
Medicare Taxable Compensation________ x_________ % = ___________ Medicare Tax
Tier II Taxable Compensation __________ x___________ % = ___________ Tier II Tax
Total Employer Tax ___________
Employee Tax Calculation:
Tier I Taxable Compensation ___________ x___________ % = ___________ Tier I Tax
Medicare Taxable Compensation________ x_________ % = ___________ Medicare Tax
Tier II Taxable Compensation __________ x___________ % = ___________ Tier II Tax
Total Employee Tax ___________
Section 5: Railroad Unemployment Insurance Act Employer Contributions
RUIA contributions are calculated using the rates and monthly limits in effect during the months the Pay for Time Lost payments relate. RUIA creditable compensation is calculated by multiplying the service months allocated to the year by the lesser of the applicable RUIA monthly maximum or the employee’s allocated monthly compensation.
RUIA Creditable Contribution RUIA
Year Compensation x Rate = Contribution
_____ ______________ x ________ = ____________
_____ ______________ x ________ = ____________
_____ ______________ x ________ = ____________
_____ ______________ x ________ = ____________
_____ ______________ x ________ = ____________
_____ ______________ x ________ = ____________
Total Employer RUIA Contribution ____________
For a general overview of the topic, see Form IB-4, “Pay for Time Lost from Regular Railroad Employment”.