ID-4Y Form Letter; Advising of Ineligibility for Sickness Bene

C~EE.Z~-T

Form Approved
3220-0025

OMB No.

U.S. RAILROAD RETIREMENT BOARD
O f f i c e of Programs - Operations
P.O. Box 10695
Chicago, I l l i n o i s 60610-0695

In r e p l y r e f e r t o
SS No.
REQ 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 under t h e
r a i l r o a d earnings.
R a i l r o a d Unemployment Insurance Act based on your .
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
through June 30, Z O O . , you 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
$
in
, c o u n t i n g no more t h a n $
f o r any month. I f 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 a r e q u a l i f i e d , complete 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 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 based on a n e x t e n s i o n of
To be e l i g i b l e f o r
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, 2001
t h e s e b e n e f i t s you must have a t l e a s t 10 y e a r s of r a i l r o a d s e r v i c e 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 reached age 65. I f you b e l i e v e t h a t
you meet t h e s e requirements, 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 provided, 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

--

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

1. In 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 . 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 space, use 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 20C

.

PLEASE READ THE IMPORTANT NOTICES ON THE REVERSE SIDE OF 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 c a u s e
payment of b e n e f i t s by t h e RRB. I a f f i r m t h a t t o t h e b e s t of 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 , complete, a n d c o r r e c t .

Signature
Enclosure:

Date
Form UI-9

PAPERWORK REDUCTION/PRIVACY ACT NOTICE
The Railroad Retirement Board's authority for requesting this information
is section 2(c) of the Railroad Unemployment Insurance Act. The
information requested on this form is needed to determine if you qualify
for benefits. You do not have to provide the information requested; but
if you fail to respond, we may not be able to pay you benefits.
We estimate this form takes an average of 5 minutes to complete,
including the time for reviewing the instructions, getting the needed
data, and reviewing the completed form. Federal agencies may not conduct
or sponsor, and respondents are not required to respond to a collection
of information unless it displays a valid OMB number. If you wish, send
comments regarding the accuracy of our estimate or any other aspect of
this form, including suggestions for reducing completion time, to Chief of
Information Management, Railroad Retirement Board, 844 N. Rush St.,
Chicago, Illinois 60611-2092.