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

Form Approved
OMB No. 3220-0025
U.S. RAILROAD RETIREMENT BOARD
Office of Programs - Operations
P.O. Box 10695
Chicago, Illinois 60610-0695
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In reply refer to
SS No. - REQ According to our records, you are not qualified for benefits under the
Railroad Unemployment Insurance Act based on your
railroad earnings.
To be qualified for benefits in the general benefit year July 1,
through June 30, B , you must have had railroad earnings of at least
$in lS@W, counting no more than $ S for any month. If you think
our records are wrong and you believe you are qualified, complete and
return the enclosed Form UI-9.
Even though you are not qualified for benefits based on your
earnings, you may now be eligible for benefits based on an extension of
the general benefit year which ended June 30, 3mSB. To be eligible for
these benefits you must have at least 10 years of railroad service and you
must not have voluntarily retired or reached age 65. If you believe that
you meet these requirements, please answer the questions below, sign your
name in the space provided, and return this letter to the address shown
above.
Robert J. Duda

-- Director of Operations

1. In counting your service months, did you include military service, if any? YesIf YOU have military service, give your entry date
and discharge date

No -.

2. Furnish the following information for each employer for whom you worked
or from whom you received vacation pay or pay for time lost in m.
If you need more space, use the other side of this notice.
Railroad :
Occupation:
Place of Employment

- City and State:

List months of service in
PLEASE READ THE IMPORTANT NOTICES ON THE REVERSE SIDE OF THIS FORM.
I understand that civil and criminal penalties may be imposed on me for
false or fraudulent statements, or for withholding information to cause
payment of benefits by the RRB. I affirm that to the best of my
knowledge, the information I have given is true, complete, and correct.
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.