ID-4F (proposed) Form Letter; Advising of Ineligibility for RUIA Benefits

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Form Approved
OMB No. 3220-0025

U.S. AILROAD RET REMENT BOARD
Office of Programs - Operations
P.O. Box 10695
Chicago, Illinois 60610-0695

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In reply refer to
SS No.

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According to our records, you are not qualified for benefits under the
Railroad Unemployment Insurance Act based on your pPr railroad earnings.
To be qualified for benefits in the general benefit year July 1, %Bb.
through June 30, %IB, you must have had railroad earnings of at least
in W , counting no more than $ U 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,
To be eligible for
these benefits you must have at least 10 years of railroad service and
must not have voluntarily left work without good cause or voluntarily
retired. 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.

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'

Robert J. Duda

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Director of Operations

In counting your service months, did you include military service, if any? Yes-No
If you have military service, give your entry date
and discharge date

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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
If you need more space, use the other side of this notice.

m.

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

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The Railroad Retirement Board's authority for requesting this information
is section 2 (3lc'bfthe 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 i~formation requested; but
if you fail to respond, we may not be able to pay yowy,benefi$g..*,.
,

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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 ~ 0 l l e ~ t i O n
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.