Form ID-20-1(proposed) Form Letter; Advising That Normal Unemployment Benefits

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-20-1 (PROPOSED)

XX-XX-XX

NAME
ADDRESS
CITY, STATE ZIP
In reply refer to
SS No.
REQ –
You are about to exhaust your normal unemployment 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.
Our records show that you have _____ service months through XXXX. If you believe you have at
least 120 months of service, complete the questions below and return this letter to the address
shown above.
Otherwise, you may apply for benefits again on or after July 1, XXXX, if you are then unemployed
and your $XX.XX 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.