Form ID-11A (proposed) ID-11A (proposed) Requesting Reason for Late Filing of Sickness Benefit

PROPOSED
Form Approved
OMB NO.3220-0039
U.S. RAILROAD RETIREMENT BOARD
Office of Programs - Operations
P.O. Box 10695
Chicago, IL 60610-0695
lD-11A (XX-XX)
In reply refer to
S.S. No.
REQ NOTICE OF LATE FILING
This is notice that your Application for Sickness Benefits and Statement of Sickness
were not received within the prescribed 10-day time limit. Because we could not tell why
your application was filed late, we can start your benefits no earlier than
. If
you tried to file your application earlier but were not able to do so, please give us the
information requested on the back of this letter.
If you complete the questions on the reverse side and return this notice, we will consider
your reason(s) for filing late and either start your benefits with an earlier date or notify
you why your benefits cannot begin earlier.
If you do not return this form but still think your benefits should start with an earlier date,
you may request reconsideration. Your request must be in writing and should explain
why you disagree with the beginning date we have established for your benefits. If you
request reconsideration, your request must be received at an office of the Railroad
Retirement Board within 60 days of the date of this letter. Please be sure to sign your
name and give your social security number on any letter that you send to us.
The RRB is authorized to collect the information requested on this form under section
5(b) of the Railroad Unemployment Insurance Act. Although you are not required to
provide the information, failure to do so could result in a loss of benefits to you. We
estimate that the form takes an average of 4 minutes to complete, including time for
reviewing the instructions, getting needed date, 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 the
form, including suggestions for reducing completion time, to the Chief of Information
Resources Management, Railroad Retirement Board, 844 North Rush Street, Chicago,
IL 60611-2092.

Robert J. Duda
Director of Operations

Form Approved
OMB NO.3220-0039
SS No.
REPLY TO NOTICE OF LATE FILING
1.

What actions did you take to obtain your Application for Sickness Benefits and
Statement of Sickness forms? List dates actions taken.

2.

What steps did you take to complete these forms and file them with the Railroad
Retirement Board? Provide the dates these steps were taken.

3.

Explain why your forms were filed late.

4.

Provide the names and titles of any persons who helped you complete and file the
forms.

5.

Do you wish to claim as days of sickness all days for which you may be entitled to
benefits prior to
?
YES - Go to item 7 -NO

6.

Enter any days you do not wish to claim.

7.

Will you receive wages or other pay (other than these benefits) for your days of
sickness?
YES
NO - Go to Item 11

8.

What kind of wages or other pay will you receive?

9.

List the exact days for which you will receive any such payments:

-

10. Who will make these payments?
11. CERTIFICA'TION: I know that disqualifications and civil and criminal penalties may
be imposed on me for false or fraudulent statements or claims or for withholding
information to get benefits from the Railroad Retirement Board. I affirm that the
information given on this form is true, correct and complete.
SIGNATURE:

DATE:

Return this form to the RRB address shown at the top of the other side of this letter.

lD-11A (XX-XX)