ID-11A Requesting Reason for Late Filing of Sickness Benefit

CYRE~JT
OMB

Form Approved
No. 3220-0039

U.S. RAILROAD RETIREMENT BOARD

O f f i c e of Programs - Operations
P.O. BOX 10695
Chicago, I l l i n o i s 60610-0695
'

ID-11A

(02-01)

In reply r e f e r t o
SS No.
REQ

-

NOTICE OF LATE FILING
T h i s i s n o t i c e t h a t your A p p l i c a t i o n f o r Sickness B e n e f i t s and Statement
of S i c k n e s s were n o t r e c e i v e d w i t h i n t h e p r e s c r i b e d 10-day time l i m i t .
Because we could n o t t e l l why your a p p l i c a t i o n was f i l e d l a t e , we c a n
s t a r t your b e n e f i t s no e a r l i e r t h a n
I f you t r i e d t o f i l e your
a p p l i c a t i o n e a r l i e r b u t were n o t able t o do s o , p l e a s e g i v e u s t h e
i n f o r m a t i o n r e q u e s t e d on t h e back of t h i s l e t t e r .

.

If you complete t h e q u e s t i o n s on t h e r e v e r s e s i d e and r e t u r n t h i s n o t i c e ,
we w i l l c o n s i d e r your r e a s o n ( s ) f o r f i l i n g late and e i t h e r start your
b e n e f i t s w i t h an e a r l i e r d a t e o r n o t i f y you why your b e n e f i t s cannot begin
earlier.
If you d o n o t r e t u r n t h i s form b u t s t i l l t h i n k your b e n e f i t s should s t a r t
w i t h a n earlier d a t e , you may r e q u e s t r e c o n s i d e r a t i o n .
Your r e q u e s t must
be i n w r i t i n g and should e x p l a i n why you d i s a g r e e w i t h t h e beginning d a t e
we have e s t a b l i s h e d f o r your b e n e f i t s . If you r e q u e s t r e c o n s i d e r a t i o n ,

your r e q u e s t must be r e c e i v e d a t a n o f f i c e of t h e R a i l r o a d Retirement
Board w i t h i n 60 days of t h e d a t e of t h i s l e t t e r . P l e a s e be s u r e t o s i g n
your name and g i v e your s o c i a l s e c u r i t y number on any l e t t e r t h a t you send
t o us.
The RRB i s a u t h o r i z e d t o c o l l e c t t h e information requested on t h i s form
under s e c t i o n 5(b) of t h e R a i l r o a d Unemployment Insurance A c t . Although
you a r e n o t r e q u i r e d t o provide t h e i n f o r m a t i o n , f a i l u r e t o do s o c o u l d
r e s u l t i n a l o s s of b e n e f i t s t o you. We e s t i m a t e t h a t t h e form t a k e s an
zverage of 3 minutes t o complete, i n c l u d i n g time f o r reviewing t h e
i n s t r u c t i o n s , g e t t i n g needed d a t a , and reviewing t h e completed form.
F e d e r a l a g e n c i e s may n o t conduct o r sponsor, and respondents a r e n o t
r e q u i r e d t o respond t o a c o l l e c t i o n of i n f o r m a t i o n u n l e s s i t d i s p l a y s a
v a l i d OMB number. I f you w i s h , send comments r e g a r d i n g t h e accuracy of
our e s t i m a t e o r any o t h e r a s p e c t s of t h e form, i n c l u d i n g s u g g e s t i o n s f o r
r e d u c i n g completion t i m e , t o the..C_hief of Information Management, R a i l r o a d Retirement Board, 844 N Rush S t , Chicago, I1 60611-2092.

Robert J . Duda
D i r e c t o r of Operations

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OMB

Form Approved
No. 3220-0039

REPLY TO NOTICE OF LATE FILING

1. What a c t i o n s d i d you t a k e t o o b t a i n your A p p l i c a t i o n f o r s i c k n e s s

B e n e f i t s and Statement o f S i c k n e s s forms? L i s t d a t e s a c t i o n s taken.

2 . What s t e p s d i d you t a k e t o complete t h e s e forms and f i l e them w i t h t h e

R a i l r o a d Retirement Board?

P r o v i d e t h e dates t h e s e s t e p s were taken.

3 . P r o v i d e t h e names and t i t l e s o f any persons who h e l p e d you complete and

f i l e t h e forms.
4. Do you wish t o claim as d a y s o f s i c k n e s s a l l d a y s f o r which you may

e n t i t l e d t o b e n e f i t s p r i o r t o 05-27-03?

-YES-

Go t o I t e m 6

-NO

5. E n t e r any days you do n o t wish t o claim.

6. W i l l you r e c e i v e wages o r o t h e r pay ( o t h e r t h a n t h e s e b e n e f i t s ) f o r

y o u r d a y s of s i c k n e s s ? -YES

-NO-

Go t o Item 1 0

7. What k i n d of wages o r o t h e r pay w i l l you r e c e i v e ?

8. L i s t t h e exact days f o r which you w i l l r e c e i v e any such payments:

9. Who w i l l make t h e s e payments?

1 0 . CERTIFICATION: I know t h a t d i s q u a l i f i c a t i o n s and c i v i l a n d c r i m i n a l
p e n a l i t e s may be imposed on me f o r f a l s e o r f r a u d u l e n t s t a t e m e n t s o r
claims o r f o r wit_hh.oging i n f o r m a t i o n t o g e t b e n e f i t s from t h e , -R a i l r o a d Retirement Board. I a f f i r m t h a t t h e i n f o r m a t i o n given on
t h i s form i s t r u e , c o r r e c t and complete.
SIGNATURE :

DATE :

R e t u r n t h i s form t o t h e RRB a d d r e s s shown a t t h e t o p of t h e o t h e r
s i d e of t h i s l e t t e r .

be