ID-20-4 Form Letter; Advising that Normal Sickness Benefits are

Form Approved
3220-0025

OMB No.

U.S. RAILROAD RE.TIREMENT 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 r e f e r t o
SS No.
REQ - 7699
You a r e a b o u t t o e x h a u s t 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 a r e 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 and a r e age 65 o r over.
and
Our r e c o r d s show t h a t you have 089 months of s e r v i c e t h r o u g h :
t h a t you were born i n 1930. I f you have a t l e a s t 120 months of s e r v i c e
and have n o t reached age 65, 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. Also, send us a copy of your b i r t h
c e r t i f i c a t e o r o t h e r proof of a g e .
Otherwise, you may a p p l y f o r b e n e f i t s Tgain on o r a f t e r J u l y 1,
if
railroad earnings a r e at l e a s t
you a r e t h e n unable t o t w o r k and y o u r
I , c o u n t i n g no more t h a n
f o r any month.
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 :

Military Service
Railroad Service After

Yes
Yes

No No

.

, furnish t h e following information
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 time l o s t . 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 .

2 . I f you i n c l u d e d s e r v i c e a f t e r

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

I:

PLEASE READ THE IMPORTANT NOTICES ON THE REVERSE SIDE OF T H I S 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 , complete and c o r r e c t .

Signature

Date

PAPERWORK REDUCTION/PRIVACY ACT NOTICE

The R a i l r o a d Retirement Board'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 Insurance 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 do n o t have t o provide 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 complete,
i n c l u d i n g t h e time f o r reviewing 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 reviewing 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 respondents a r e n o t r e q u i r e d t o respond 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 you w i s h , send
comments r e g a r d i n g t h e accuracy of o u r e s t i m a t e o r any 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 completion t i m e , t o Chief of
Information 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.