ID-20-2 Form Letter; Advising that Normal Sickness Benefits Are

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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
Chicago, I l l i n o i s 60610-0695

In reply refnSS No.
REQ - 7695

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You a r e about t o exhaust your normal s i c k n e s s b e n e f i t s . For t h i s r e a s o n
you may r e c e i v e a s m a l l e r check t h a n u s u a l . You are n o t e n t i t l e d t o
extended b e n e f i t s because you a p p a r e n t l y do n o t have 120 o r more months
of r a i l r o a d s e r v i c e .

. I f you
Our r e c o r d s show t h a t you have 012 s e r v i c e months t h r o u g h
b e l i e v e you have at l e a s t 120 months of s e r v i c e , complete t h e q u e s t i o n s
below 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.
, if
Otherwise, you may a p p l y f o r b e n e f i t s a g a i n on o r a f t e r J u l y 1,
you a r e t h e n unable t o work and y o u r 200. r a i l r o a d e a r n i n g s a r e a t l e a s t
$2512.50, c o u n t i n g no more t h a n
f o r any month.
R o b e r t J . Duda
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 :

Military Service
Railroad s e r v i c e After

Yes
Yes

,

No
No

furnish t h e following information,
2. I f you, i n c l u d e d s e r v i c e a f t e r :
f o r e a c h 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 . If 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 a f t e r
PLEASE READ THE IMPORTANT NOTICES ON THE REVERSE SIDE O F THIS FORM.
I u n d e r s t a n d 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 , c o m p l e t e and c o r r e c t .

Signature

Date

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.