ID-4U (proposed) Form Letter; Advising of Service/Earnings Requirements f

Form Approved
3220-0025

OMB No.

O f f i c e of Programs - Operations
P.O. Box 10695
Chicago, I l l i n o i s 60610-0695
I D - I U &X-.Xx)

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In reply r e f e r t o
SS No.
RE&

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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 under t h e
earnings.
R a i l r o a d Unemployment I n s u r a n c e A c t based on your - r a i l r o a d
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, 1PQ
through June 30, n,
you must have had r a i l r o a d e a r n i n g s of a t least
$
i n -,
c o u n t i n g no more t h a n $ W 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 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 f o r which you would normally
become q u a l i f i e d on J u l y 1, m. 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 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
least -$
i n O*, and you must n o t have v o l u n t a r i l y q u i t work
w i t h o u t 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 . If 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 your name i n
t h e s p a c e 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
1.

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

In counting your service months, did you include military service, if any? Yes- NO-.
If you have military service, give your entry date
and discharge date

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
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 .

m.

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

-.

PLEASE READ THEIMPORTANT 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 and c r i m i n a l p e n a l t i e s may b e imposed on me f o r
false o r fraudulent 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
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 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
Enclosure:

Date

Form UI-9

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PAPERWORK REDUCTION/PRIVACY ACT NOT~CE
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 ingormation requested; but
if you fail to respondIn.wemay not be able to pay you,,+nefits.
. a +

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 oFile Typeapplication/pdfFile Modified2007-02-14File Created2007-02-14