ID-20-4 (proposed) Form Letter; Advising That Normal Sickness Benefits Are

PROPOSED
Form Approved
OMB No. 3220-0025
U.S. RAILROAD RETIREMENT BOARD
Office of Programs – Operations
Post Office Box 10695
Chicago, Illinois 60610-0695

ID-20-4 (PROPOSED)

12-18-XX

NAME
ADDRESS
CITY, STATE ZIP
In reply refer to
SS No.
REQ –
You are about to exhaust your normal sickness benefits. For this reason you may receive a smaller
check than usual. You are not entitled to extended benefits because you apparently do not have
120 or more months of railroad service and are age 65 or over.
Our records show that you have _____ months of service through XXXX, and that you were born in
XXXX. If you have at least 120 months of service and have not reached age 65, complete the
questions below and return this letter to the address shown above. Also, send us a copy of your
birth certificate or other proof of age.
Otherwise, you may apply for benefits again on or after July 1, XXXX, if you are then unable to work
and your railroad earnings are at least $XX.XX, counting no more than $XX.XX for any month.
Robert J. Duda – Director of Operations
1. In counting your total months of service:
Did you include military service, if any? Yes____No_____.
If you have military service, give your entry date XXXX and discharge date XXXX.
Did you include railroad service after XXXX? Yes_____No_______
2. If you included service after XXXX, furnish the following information for each employer for
whom you worked or from you received vacation pay or pay for time lost. If you need more
space, use the other side of this notice.
Railroad:____________________________________________________________________
Occupation:________________________________________________________________
Place of Employment – City and State:_____________________________________
List months of service after: XXXX ___________________________________________
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 payments 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___________________________

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 Street, Chicago, Illinois 60611-2092.