ES-21 (proposed) Referral to State Employment Service

Form Approved
OMB NO.3220-0057

U.S. RAILROAD RETIREMENT B O A R D

In reply refer toSS No.:

Report on or before:

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Please report in person to the State Employment Service (SES) office shown above and apply for work to which you
may be referred by that office.
Instructions for Completing Part A and Part B
When you report to the SES office, give this notice and the postaqe paid envelope to the SES representative.
Have the SES representative complete ltern 1 below and return this page to you.
You must sign and date ltem 3 then use the postaqe due envelope to return this page to our address shown above.
The SES representative will complete and return the next page (Part B) in the postaqe paid envelope.
If vou do not report to the SES office, you must complete Items 2 and 3 and return this notice to us no later than the
date you are to report.
NOTE: If you fail to report to the SES office or to comply with the office's instructions, you may be disqualified from
receiving unemployment benefits for a period of 30 days.
REFERRAL T O STATE EMPLOYMENT SERVICE (PART A )
(To be completed by State Employment Service Office. Return this page to the applicant and then go to
ltem 1
PART B on the next page.)
Date applicant reported:
SES Office Stamp:

ltem 2

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

ltern 3

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Your Signature
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PAPERWORK REDUCTION ACTIPRIVACY ACT NOTICE

Date

The information requested on this form will be used by the Railload Retirement Board (RRB) to determine our eli ibility for
unemployment benef~ts.The RRBJsauthqr~tyfor request~ngthls lnfor.rnatlo? IS sect~on5(b) of the ~allroad&nem?oyment
Insurance Act. Although you are not requ~redto prov~deth~s~nformat~on,
fallure to do so may prevent payment orbenefits to
you.
We estimate this form takes less than 1 minute to com lete, including the time needed for reviewing the instructions, getting
the needed data. and reviewin the com leted form. Aderal agencies ma not conduct or sponsor and respondents are not
required to respond to. a co~~eAion
of inirmation unless it displays a valid ~ M number.
B
If you wish, send comments
regardin the accuracy of our estimate or any other aspect of this form. including su#festions for reducin the completion
time to:%hlef of lnformat~onResources Management. Ra~lroadRetlrement Board, 4 N. Rush Street, cfiicago, IL
6061 1-2092.

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