ID-4X Form Letter; Advising of Service/Earnings Requirements f

C d ~ s ~ h f T

Form Approved
3220-0025

OMB No.

U.S. RAILROAD RETIREMENT BOARD
O f f i c e o f Programs - O p e r a t i o n s
P.O. Box 10695
C h i c a g o , I l l i n o i s 60610-0695

In reply recar
SS No.
REQ

tn

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According t o o u r 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 u n d e r t h e
R a i l r o a d Unemployment-Insurance A c t based on y o u r
railroad 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, 200
t h r o u g h J u n e 30, 20C , y'ou must have had r a i l r o a d e a r n i n g s of a t l e a s t
c
in
, c o u n t i n g no more t h a n $
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 a n d you b e l i e v e you a r e q u a l i f i e d , c o m p l e t e
and r e t u r n t h e e n c l o s e d 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 b a s e d on y o u r
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 f o r which you would
To be e l i g i b l e f o r t h e s e
normally become q u a l i f i e d on J u l y 1, 200
b e n e f i t s you must have a t l e a s t 1 0 y e a r s of r a i l r o a d s e r v i c e , r a i l r o a d
e a r n i n g s of a t l e a s t :
i n 200
and you must n o t have v o l u n t a r i l y
r e t i r e d o r r e a c h e d a g e 65. I f you b e l i e v e t h a t you meet t h e s e
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 y o u r name i n t h e
s p a c e 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 a b o v e .
Robert J. Duda - - ' D i r e c t o r

of Operations

1. I n c o u n t i n g your t o t a l months o f 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

Yes- No-

service?

2. F u r n i s h 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 t i m e 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 o f 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 20(

:

PLEASE READ THE IMPORTANT NOTICES ON THE REVERSE SIDE OF THIS FORM.
I u n d e r s t a n d t h a t c i v i l a n d 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 statements, o r f o r withholding information t o cause
payment o f b e n e f i t s by t h e RRB. I affirm t h a t t o t h e b e s t o f my
knowledge, t h e i n f o r m a t i o n I have g i v e n i s t r u e , c o m p l e t e , a n d 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 A c t . 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 r e s p o n d , 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 a r e 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. If you w 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 of 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
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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.