Form ID-4K Prepayment Claims Verification Notice

FORM APPROVED
OMB NO. 3220-0171
U.S. Railroad Retirement Board
O f f i c e of Programs - Assessment and Training
844 North Rush Street
Chicago, I l l i n o i s
60611-2092

BRIDGET SHEPARD
BUFFALO 8 PITTSBURGH RAILROAD. TNC.
1200-C SCOTTSVILLE RD
STE 200
ROCHESTER, NY 14624

PREPAYMENT NOTICE OF EMPLOYEESf APPLICATIONS
AND CLAIMS FOR BENEFITS UNDER THE RAILROAD
UNEMPLOYMENT INSURANCE ACT

The f o l l o w i n g i s a r e p o r t of unenployment applications. unenployment claims and sickness claims f i l e d
by current o r former enployees of your colnpany under the Railroad Unenployment Insurance Act. To help
ensure t h a t benefits are paid c o r r e c t l y t o the employees, please conpare the information on t h i s report
w i t h your enployment s t a t u s and p a y r o l l records. N o t i f y the Railroad Retirement Board o f f i c e i d e n t i f i e d i n the l a s t column of the report by telephone w i t h i n 3 business days i f you f i n d t h a t the enployee
( 1 ) i s unenployed f o r a reason other than t h a t reported. ( 2 ) reported an i n c o r r e c t date l a s t worked.
( 3 ) i s claiming b e n e f i t s f o r days on which he o r she worked o r i s e n t i t l e d t o vacation pay, holiday pay
o r Other wages or remuneration, o r ( 4 ) i s claiming b e n e f i t s f o r days on which he o r she was v o l u n t a r i l y
absent from work.
I f you do not respond w i t h i n 3 days from the date of t h i s n o t i c e b u t have information
t o provide, please mail your response t o the RRB o f f i c e shown. NO REPLY TO THIS REPORT I S NECESSARY I F
THE INFORMATION PROVIDED BY THE EMPLOYEE I S CORRECT AND YOU HAVE NO OTHER INFORMATION TO PROVIDE.
I f no "Date Last Worked" and "Reason Unenployedll are shown, the report i s f o r a c l a i m f o r sickness benefits.
I f no "Claim Beginning Date" and "Claim P r o f i l e b 1are shown, the r e p o r t i s f o r an a p p l i c a t i o n
f o r unemployment benefits. An 81N11
f o l l o w i n g the UDate Last Worked1' indicates t h a t the date i s a
reported date l a s t worked f o r a non-railroad enployer. The 14 codes i n the c l a i m p r o f i l e indicate the
employee's status on the days i n the claim period. The codes are as follows:
0
Day not claimed;
1
claimed day of unemployment o r sickness; 2
Day of enployment; 4, 5, 6, 8, and 9
Claimed day
denied by the RRB.
Contact your l o c a l RRB o f f i c e i f you need additional information. For additional
r e p o r t i n g instructions, please r e f e r t o Program L e t t e r UI-C-229.

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SS NUMBER
NAME

-

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PAYROLL ID NO.

DATE LAST WORKED
REASON UNEMPLOYED

CLAIM BEG. DATE
CLAIM PROFILE

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EARNINGS

RRB OFFICE
TELEPHONE NUMBER

BIRMINGHAM AL
205-731 -0019