ID-20-4 Form Letter; Advising that Normal Sickness Benefits are

Form Approved
OMB No. 3220-0025

u.s. RAILROAD RETIREMENT BOARD
Office of Programs - Operations
P.O. Box 10695
Chicago, Illinois 60610-0695
ID-20-4 (08-07)

02-16-10

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In reply refer to
SS No.
REQ ­

You are about to exhaust your normal sickness benefits. For this reason
you may receive a smaller check than usual. You are not entitled to
extended benefits because you apparently do not have 120 or more months
of railroad service and are age 65 or over.
Our records show that you have
months of service through
, and
that you were born in
If you have at least 120 months of service
and have not reached age 65, complete the questions below and return this
letter to the address shown above. Also, send us a copy of your birth
certificate or other proof of age.
Otherwise, you may apply for benefits again on or after July 1,
, if
you are then unable to work and your
railroad earnings are at least
$.
~OO, counting no more than $
for any month.
Robert J. Duda - Director of Operations
1. In counting your total months of service:
Did you include military service, if any?
Yes
No
If you have military service,give your entry date
and discharge date
Did you include Railroad Service After

Yes

No

2. If you included service after
, furnish the following information
for each employer for whom you worked or from whom you received
vacation payor pay for time lost. If you need more space, use the
other side of this notice.
Railroad:
Occupation: ______________________________________________________________
Place of Employment - City and State:
List months of service after
PLEASE READ THE IMPORTANT NOTICES ON THE REVERSE SIDE OF THIS FORM.
I understand that civil and criminal penalties may be imposed on me for
false or fraudulent statements, or for withholding information to cause
payment of benefits by the RRB.
I affirm that to the best of my
knowledge, the information I have given is true, complete and correct.
Signature

Date

PAPERWORK REDUCTION/PRIVACY ACT NOTICE
The Railroad Retirement Board's authority for requesting this information
is section 2(c) of the Railroad Unemployment Insurance Act. The
information requested on this form is needed to determine if you qualify
for benefits. You do not have to provide the information requested; but
if you fail to respond, we may not be able to pay you benefits.
We estimate this form takes an average of 5 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 aspect of
this form, including suggestions for reducing completion time, to Chief of
Information Management, Railroad Retirement Board, 844 N. Rush St.,
Chicago, Illinois 60611-2092.