ES-21 Referral to State Employment Service

CURP~M~'

Form Approved
OMB NO.3220-0057

U.S. RAILROAD RETIREMENT BOARD

In reply refer to SS No.:

Report to State Employment Service Office at:

Report on or before:

REFERRAL TO STATE EMPLOYMENT SERVICE (PART A)
This is notice that you are to report in person to the State Employment Service (SES) office shown above and appl for
work to which you may be referred by that office. Give this notice and the enclosed postage paid envelope to the
representative when ou report. After havin the SES re resentative complete ltem 1 below, please sign and date the
form in ltem 3 and rerurn thls a e to us at t i e address s own above in the enclosed postage due envelope. The SES
representative should complere R e second page of this notice and return it to us in the postage paid envelope.
If you fail to re ort to the SES office or to comply with the office's instructions ou may be disqualified from receiving
unemploymenf)benefits for a period of 30 days. If you do not report to the
office. complete Items 2 and 3 and
return thls notice to us no later than the date you are to report.
ltem 1
(To be completed by State Employment Service Office. Return this page to the applicant and then go to
PART B on the next page.)

JES

f:

Date applicant reported:
SES Office Stamp:

ltem 2

1

(To be completed by applicant) If you do not report to the SES office, enter reason:

Your Signature

Date

PAPERWORK REDUCTION ACTlPRlVACY ACT NOTICE

The information requested on this form will be used by the Railroad Retirement Board (RRB) to determine your eli ibility for
unemployment benefits. The RRB's authority for requesting this information is section 5(b) of the Railroad Unem goyment
Insurance Act. Although you are not required to provide this information, failure to do so may prevent payment o!benefits to
you.
We estimate this form takes less than 1 minute to complete, including the time needed 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 reducin the completion
time, to: Chief of Information Resources Management. Railroad Retirement Board. 844 N. Rush Street, c\icago, IL
6061 1-2092.

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