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Employer Reporting Instructions
Appendix 2: Pay for Time Lost Worksheet
Appendix 1 Appendix 2 Appendix 3 Appendix 4

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 need 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 (3A)                X 10  =                       
C. Total Allocated Compensation:
Minimum Monthly Compensation (3B)                  X Total Allocated Service Months (2E)                  =                         

 

Section 4: Railroad Retirement Tax Act Calculation

Employer Tax Calculation
Tier I Taxable Compensation                                 X  6.2% =                              Tier I Tax
Medicare Taxable Compensation                             X  1.45% =                              Medicare Tax
Tier II Taxable Compensation                                 X  (Note: Each Year the Percentage is different) =                              Tier II Tax
Total Employer Tax                                 

 

Employee Tax Calculation
Tier I Taxable Compensation                                 X  6.2% =                              Tier I Tax
Medicare Taxable Compensation                             X  1.45% =                              Medicare Tax
Tier II Taxable Compensation                                 X   4.9% =                              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.

 

Year RUIA Creditable Compensation X Contribution Rate = RUIA Contribution
         X   =                       
         X   =                       
         X   =                       
         X   =                       
         X   =                       
         X   =                       

Total Employer RUIA Contribution                           

 

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1-23-2003