ID-4X (proposed) Form Letter; Advising of Sickness/Earnings Requirements

Form Approved
3220-0025

OMB No.

U.S. RAILROAD RETIREMENT BOARD
O f f i c e o f Programs - Operations
P-0. Box 10695
Chicago, I l l i n o i s 60610-0695

-

In reply r e f e r t o
SS No.
RE& According t o our 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.
Railroad Unemployment Insurance A c t 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,
through June 30, -,
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
$ni-,
counting no more t h a n $ - f o r
any month. If you
t h i n k our records a r e wrong and you b e l i e v e you are q u a l i f i e d , complete
and r e t u r n t h e enclosed Form UI-9.

e'

Even though you a r e not 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,
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 10 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
i n a#8, and you must n o t have v o l u n t a r i l y
e a r n i n g s of a t l e a s t $r e t i r e d o r reached ag& 65. If 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
1.

--

D i r e c t o r o f Operations

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. Furnish t h e following i n f o r m a t i o n f o r each employer f o r whom l o u 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 3SSSF.
If 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 .
R a i l road :

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 iww:

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 cause
I affirm t h a t t o t h e best of my
payment of b e n e f i t s by t h e RRB.
knowledge, t h e information I have g i v e n i s t r u e , complete, and 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
-.forbenefits. 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.