Form ID-3s (proposed) ID-3s (proposed) Request for Lien Information

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United States of America
Ratlroad Retirement Board

FORM APPROVED
OM0 NO. 3220-0036

REQUEST FOR
LIEN INFORMATION
REPORT OF SETTLEMENT

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To:

(See Important Notices Below)

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Railroad Retirement Board
Office of Programs - Operations
Attn: Sickness and Unemployment Benefits
Telephone: (312) 751-4820
Fax No. : (312) 751-7185

RRB
USE
ON LY

-

Employee's
Name

I*

SS Number

~

information

Date of
InjlJly

1 1 1
No

yes

-

8.

..

~

Return t o
Work

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9. Payor Code:

FOR RAILROAD USE ONLY
Settled

"Yest' enter date.l"Yesn enter d a t e
"No" go to 11.
"No" go to 8.

* Pay for Time Lost
From

1

To

Amount
Protected
8
Amount of
Settlemenl

Billing Doc ID
Lien
Amount

1 1
**Final

If any part of the settlement is apportioned to pay for time lmt, show the exact mnths or other time period to which pay is allocated, or fax a copy of the ~portionmentstatement.

**

If the lien amount shown is "Not Final," the amount is valid for settlement and reimbursement purposes only if you inform the RRB within 5 days that settlement has been
made. Otherwise, additional benefits may be paid to the employee. All settlements and final judgments must be reported to the RRB i n writing within 5 days of the date
of settlement or judgment. Notice may be made by facsimile using this form. The report of settlement is required to prevent additional benefit payments to the employee, and
to provide Payor Code and Billing Doc ID information for the amount due the RRB under section 12(0) of the RUIA.

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bailroad:
city:

State:

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Telephone:

(

Name of Requestor:

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1

Date Completed

1

1

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Date Returned

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Comments:

II

Fax No. : (
Date:

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I RRB Representative

.
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f
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g under section
n
12(0) of the Railroad Unemployment Insurance Act
(RUIA). Billing Document ID'S are provided ONLY for cases which have been settled. If payment is by check, return a copy of this form with your remittance, or be sure to
show your Payor Code (item 9) and the Billing Doc ID (item 10) on your check.

Notices: The RRB's completed reply is confirmation of the amount of the u

AMOUNTS DUE THE RRB UNDER SECTION 12(0) MUST BE RECEIVED WITHIN 30 DAYS AFTER THE DATE OF THE SElTLEMENT AGREEMENT OR THE ENTRY OF
FINAL JUDGMENT. AMOUNTS THAT ARE NOT PAID WITHIN 30 DAYS ARE SUBJECT TO INTEREST CHARGES FROKTHE DATE OF SElTLEMENT OR JUDGMENT.

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Form ID-3s

INSTRUCTIONS
Please complete the following items and send this form via facsimile to the Railroad Retirement Board, Office of Programs - Sickness a n d
Unemployment Benefits Section a t (3 12) 75 1-7185.

ITEM
1. Enter the employee's first initial, middle initial and last name. Do not enter a partial name.
2. Enter the employee's social security number.

3. Enter the earliest date of occurrence of the injury for which a settlement is being made. If more than one injury is being settled, enter
applicable dates.

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4. Check "YES" if you are making an informational inquiry on this case and no settlement will be issued to the employee a t this time. Check "NOnif a
settlement will be issued to the employee once you receive a reply from the RRB.
Please note that a second fax report is required if you make a settlement to the employee and your first request was for "Information
Only". Your second report is required to prevent additional benefit payments to the employee and to trigger the release of a billing
statement for the amount due the RRB under section 12(0).
5. Enter an "X" in the appropriate box to indicate whether the employee has returned to work. If the employee has returned to work, enter the date he or
she returned to work.
6. If settlement documents have been signed and a settlement concluded, enter an "X" in the "Yes" box and provide the date of settlement. If settlement
has been agreed upon, but documents have not yet been signed or if settlement negotiations are proceeding, enter an "X" in the "No" box.
If a settlement is made after obtaining information about the amount of the RRB's lien, a second fax report must be make to the
RRB within 5 days of the date of the settlement. The report of settlement is required to prevent additional benefit payments to the
employee.

7. If any part of the settlement is apportioned to pay for time lost, show the exact months or other time period to which pay is allocated; or fax a copy of
the apportioned statement along with this forms.
8. Complete this section only if a settlement has been made. Enter the amount withheld from the settlement for reimbursement to the RRB and
the gross amount of the settlement. Information about the gross settlement amount is used to compute the period of time after the date of settlement
for which benefits are not payable on the basis of the same infirmity. Benefits are payable only after the amount of the benefits otherwise payable
exceed the amount of the settlement. If the'settlement exceeds $50,000, indicate only "In excess of $50,000".
9. & 10. FOR RRB USE ONLY.

11. Enter the name of the railroad responsible for making the settlement, including the other identifying information as requested

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Paperwork Reductiorl(Privacy Act NoticetJhe RRB is authorized to collect the information requested on Form ID-3s under section 5@) of the Railroad Unemployment
Insurance Act (RUIA). The information is needed to determine the amount of sickness benefits reimbursable under section 12(0)of the (RUIA). Because you are required to
provide this information under section 9(a) of the RUIA, failure to complete and return this form could result in a fine or imprisonment or both.
We estimate &t this form takes an average of 3 minutes to complete, including the time 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 aspec of this form, including suggestions for reducing completion time, to the
Chief of Informatio Management, Railroad Retirement Board, 844 Rush St., Chicago, Illinois.

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