ID-4F Form Letter; Advising of Ineligibility for RUIA Benefits

Form Approved
CL)ZKEAIT OMB
No. 3220-0025
U.S. RAILROAD RETIREMENT BOARD
O f f i c e of Programs - O p e r a t i o n s
P . O . Box 10695
Chicago, I l l i n o i s 60610-0695

I n r e p l y refer t o
SS No.
REQ -

According t o our r e c o r d s , you a r e n o t q u a l i f i e d f o r b e n e f i t s under t h e
R a i l r o a d Unemployment I n s u r a n c e Act based on your
r a i l r o a d earnings.
To be q u a l i f i e d f o r b e n e f i t s i n t h e g e n e r a l b e n e f i t y e a r J u l y 1, 20t
through June 3n 200 , you must have had r a i l r o a d e a r n i n g s o f a t least
i n . , c o u n t i n g no more than $ 970 f o r any month. If you t h i n k
o u r r e c o r d s a r e wrong and you b e l i e v e you are q u a l i f i e d , complete and
r e t u r n t h e enclosed Form UI-9.
Even though you a r e n o t q u a l i f i e d f o r b e n e f i t s based on your
e a r n i n g s , you may now be e l i g i b l e f o r b e n e f i t s baced on a n e x t e n s i o n of
t h e g e n e r a l b e n e f i t y e a r which ended June 30, 200 . To be e l i g i b l e f o r
t h e s e b e n e f i t s you must have a t least 10 y e a r s of r a i l r o a d s e r v i c e and
must n o t have v o l u n t a r i l y l e f t work without good c a u s e o r v o l u n t a r i l y
r e t i r e d . I f you b e l i e v e t h a t you meet these r e q u i r e m e n t s , p l e a s e answer
t h e q u e s t i o n s below, s i g n your name i n t h e space p r o v i d e d , and r e t u r n t h i s
l e t t e r t o t h e a d d r e s s shown above.
Robert J. Duda

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D i r e c t o r of O p e r a t i o n s

1. I n c o u n t i n g your t o t a l months of s e r v i c e , d i d you i n c l u d e m i l i t a r y

service?

Yes- No-

2. Furnish t h e f o l l o w i n g i n f o r m a t i o n f o r each employer f o r whom you worked
o r from whom you r e c e i v e d v a c a t i o n pay o r pay f o r time l o s t i n 2000.
I f you need more s p a c e , u s e t h e o t h e r s i d e of t h i s n o t i c e .
Railroad :
Occupation:
P l a c e of Employment

-

C i t y and S t a t e :

L i s t months of s e r v i c e i n 200t.:

PLEASE READ THE IMPORTANT NOTICES ON THE REVERSE SIDE O F THIS FORM.
I understand t h a t c i v i l and c r i m i n a l p e n a l t i e s may be imposed on me f o r
f a l s e o r f r a u d u l e n t s t a t e m e n t s , o r f o r withholding i n f o r m a t i o n t o cause
I a f f i r m t h a t t o t h e b e s t of my
payment of b e n e f i t s by t h e RRB.
knowledge, t h e i n f o r m a t i o n I have given i s t r u e , complete, and c o r r e c t .

Signature
Enclosure:

Date
Form UI-9

PAPERWORK REDUcTION/PRIVACY

ACT NOTICE

The R a i l r o a d R e t i r e m e n t B o a r d ' s a u t h o r i t y f o r r e q u e s t i n g t h i s i n f o r m a t i o n
i s s e c t i o n 2 ( c ) of t h e R a i l r o a d Unemployment I n s u r a n c e Act. The
i n f o r m a t i o n r e q u e s t e d on t h i s form i s needed t o d e t e r m i n e i f you q u a l i f y
f o r b e n e f i t s . You d o n o t have t o p r o v i d e t h e i n f o r m a t i o n r e q u e s t e d ; b u t
i f you f a i l t o respond, we may n o t be a b l e t o pay you b e n e f i t s .

,

We e s t i m a t e t h i s form t a k e s a n a v e r a g e of 5 minutes t o c o m p l e t e ,
i n c l u d i n g t h e t i m e f o r r e v i e w i n g t h e i n s t r u c t i o n s , g e t t i n g t h e needed
d a t a , and r e v i e w i n g t h e completed form. F e d e r a l a g e n c i e s may n o t conduct
o r s p o n s o r , and r e s p o n d e n t s are n o t r e q u i r e d t o r e s p o n d t o a c o l l e c t i o n
of i n f o r m a t i o n u n l e s s i t d i s p l a y s a v a l i d OMB number. I f y ~ w
u i s h , send
comments r e g a r d i n g t h e a c c u r a c y o f o u r e s t i m a t e o r a n y o t h e r a s p e c t of
t h i s form, i n c l u d i n g s u g g e s t i o n s f o r reducing c o m p l e t i o n t i m e , t o Chief of
I n f o r m a t i o n Management, R a i l r o a d Retirement Board, 844 N. Rush S t . ,
Chicago, I l l i n o i s 60611-2092.