Form ID-5S(SUP) (09-01) ID-5S(SUP) (09-01) Report of Case for Which All Days were Claimed During a

CURRENT

REPORT OF CASES FOR WHICH ALL DAYS
WERE CLAIMED DURING A MONTH CREDITED PER
AN ADJUSTMENT REPORT PROCESSED FOR 1998
EMPLOYER: 1321

Norfolk Southern RR

SSN
-

EMPLOYEE
NAME

BA4 ADJUSTMENT
PROCESS DATE
07-1 5-99

MONTH(S)
EMPLOYER
CREDITED
REPLY
OCT
JAN
FEB JUN SEP OCT NOV
JAN
NOV

EMPLOYER CERTIFICATION: THE INFORMATION IN THIS REPORT IS CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.
SIGNATURE
FORM ID-5s (SUP)(09-01)

OFFICIAL CONTACT: NAME

TELEPHONE NO. (

)