ID-8K (proposed) Letter to Union Representative

FRO p o s e 9

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0 164

SOCIAL SECURITY NUMBER

-

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,

B

PAPERWORK REDUCTION ACT NOTICE

This notice is given under the Papework 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 Insurance Act. The information IS needed to help
determine the clai.mant's availability for work and whether the clamant received back pay for time lost. Your obligation to
prov~deus wlth thls ~nformatlonIS voluntary.
We esti,mate this, form takes an average of 5 minutes per response to corn lete, including the time for reviewing the
instructlons. gettlng the needed data and revlewlng the completed form. R d e r a ~agencies ma not conduct or sponsor. and
respondents are not required to respond to. a collection of information unless it displays v a l i d ( 0 ~ Bnumber. if you with,
send comments regarding the accuracy of our est~mateor any other aspect of this form, including sug estions for reduclng
the completion time. to the Chief of Information Resources Management, Railroad Retirement Board, i44 North Rush St.
Chicago, IL 6061 1-2092.

s

1. Are you currently handling this employee's case for reinstatement?

OYes

ONo

2. Is pay for time lost being claimed?

OYes

ONo

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: (

)

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