ID-4X Form Letter; Advising of Service/Earnings Requirements f

Form Approved
OMB No. 3220-0025
U.S. RAILROAD RETIREMENT BOARD

Office of Programs - Operations

P.O. Box 10695

Chicago, Illinois 60610-0695
ID-4X (08-07)

02-08-10

1.11 ••• 11 ••• 1.1.11", I ~ .1 •••• 11.1.1 •• 1•• 1.1 •• 111 ••• 1••• 1.1 •• 1'
REQ - 3010
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,
i,
you must have had railroad earnings of at least
$.
.00 in
. counting no more than $
,for any month. I f 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 for which you would
normally become qualified on July 1,
To be eligible for these
benefits you must have at least 10 years of railroad service, railroad
earnings of at least $
.00 in
, 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 total months of service, did you include military
service, if any?
Yes
No
If you have military service,give your entry date
and discharge date
-~ ~hemfOllowlng lnformatlon for each employermfor whom you worked
or from whom you received vacation payor pay for time lost in 2009.
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 2009:

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 fo~m, including suggestions for reducing completion time, to Chief of
Information Management, Railroad Retirement Board, 844 N. Rush St.,
Chicago, Illinois 60611-2092.