ID-11A (07-07) Requesting Reason for Late Filing of Sickness Benefit

Form Approved
OMB No. 3220-0039
U.S. RAILROAD RETIREMENT BOARD
Office of Programs - Operations
P.O. Box 10695
Chicago, Illinois 60610-0695
ID-11A (07-07)

,

In reply refer to
SS 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 06-12-08. 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 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 the form, including suggestions for
reducing completion time, to the Chief of Information Management, Railroad
Retirement Board, 844 N Rush St, Chicago, I1 60611-2092.

Robert J. Duda
Director of Operations

Form Approved
OMB NO. 3220-0039

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
entitled to benefits prior to 06-12-08? -YES- Go to Item 6 -NO

6. Enter any days you do not wish to claim.

7. Will you receive wages or other pay (other than these benefits) for
-NO- Go to Item 10
your days of sickness? -YES

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. CERTIFICATION: I know that disqualifications and civil and criminal
penalites 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.

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