Form ID-8K (08-04) ID-8K (08-04) Letter to Union Representative

United States of America
Railroad Retirement Board

Form Approved
OMB NO. 3220-0 164

1 SOCIAL SECURITY NUMBER
I

-

QUESTIONNAIRE REINSTATEMENT OF
DISCHARGED OR SUSPENDED EMPLOYEE

NAME

The above-named employee is claiming benefits under the Railroad Unemployment Insurance Act.
The employee has advised us that you are handlin hislher case for reinstatement. In this regard,
please answer the questions below and return the etter using the enclosed envelope. Thank you for
your cooperation in this matter.
Sincerely,

P

PAPERWORK REDUCTION NOTICE

This notice is given under the Paperwork Reduction Act of 1995. The Railroad Retirement Board's authority for collecting
the information on this form is section 12(1) of the Railroad Unemployment lnsurance Act. The information IS needed to help
determine the claimant's availability for work and whether the clamant received back pay for time lost. Your obligation to
provide us w ~ t hthis lnformat~onIS voluntary.
We estimate this form takes an average of 5 minutes per response to com lete, including the time for reviewing the
instructions. getting the needed data and review~ngt?e completed form. Aderal agencies ma not conduct or sponsor, and
respondents are not regu~redto respond to. a collection of lnformation unless it displays a . v a l i d l 0 ~number.
~
If you WIS?.
send comments regarding the accuracy of our estlmate or any other aspects of th~sform, ~ncludlngsu gest~onsfor reduclng
the completion time. to the Chief of Information Resources Management. Railroad Retirement Board. $44 North Rush St.
Chicago, IL 6061 1-2092.
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1. Are you currently handlirrg this employee's case for reinstatement?

Yes

2. Is pay for time lost being claimed?

Yes

No
No
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3. If you are no longer handling the employee's case for reinstatement,
enter the date such efforts were abandoned.

Mo.

Day

Year

4. If reinstatement efforts have been passed on to someone else, enter the following information:
NAME:
ADDRESS:
TITLE:
TELEPHONE: (

1

5. If the employee has returned or expects to return to work, enter the
date.
6. 1 certify that the information given on this form is true and complete.

SIGNATURE:

DATE:

Mo.

Day

Year