ID-4E(INTERNET) Notice of RUIA Claim Determination

ERS -New Items

00757-4h)i7/,J&

ITEM\

GIST

This is notice of the RRB's determinations on claims for benefits under the Railroad ~ n e r n ~ l o ~ mInsurance
ent
Act. Base-year service
and compensation were reported by your company for this individual. As a base year employer, you have the right to request
reconsideration of the determination to pay benefits on this notice.
Instructions: If you do not object to the payment, no action is required. Delete the record to remove it from your New Items list. If you
wish to request reconsideration of the RRB's decision to pay benefits, you may mail a request to the RRB office shown below, or you
may electronically submit your request by clicking the "SSN" link below. Your request must be received by the RRB within 60 days of
the date of this notice.
gg;f*$
i :$.Tf$

.*. -

-.?,,
-.

,. :,, 2 ,.
,,-. '1

. ..

.

.

.

.

q
1
-

Q*.

Or you may delete by Notice Date :

lo I
q

18/28/2008 ~

1

7

/

1

/

8/28/2008

q'

8/28/2008

2

0

0

7/15/2008

I,

:-

81 1111111111111
11111111111111

1

UI

i$427.00 1$427.00

jNEW YORK NY

UI

$610.00

$610.00

NEWYORKNY

$610.00

NEW YORK NY

7/29/2008
11111111111111
-

-18/2812008

1

p
p

7/29/2008

11111111111111

SI

$610.00

$610.00

BOSTON MA

1

9/4/2008

8/12/2008

11111111111111

SI

$610.00

$610.00

BOSTON MA

I

9/9/2008

5/29/2008

9191 1111111111

UI

$472.00

$472.00

BOSTON MA

t

R-t

-

LkJ-Arg~

U.S. Railroad Retirement Board
844 North Rush Street
Ch~cagoIll~no~s.
60611-2092
Telephone (312) 751-7139 TTY (312) 751-4701
Contact an RRB off~cenear vou

y,ss:-,,

ERS - ID-4E Request

'

..
~.

Reconsideration Request

Submitted By:
BA Number:2112
Name:
Email:
Phone Number:
of payments to:

SSN :
Employee Name:
Claim Begin Date: 7/1/2008
will be sent to:

./+

U.S. Ra~lroadRetirement Board
844 North Rush Street
Chicago Illinois, 60611-2092
Telephone: (312) 751-7139 TTY: (312) 751-4701
Contact an RRB office near vou

LSJ4i.gOV

,.

.-. : . 1

_I.

,

- -...: . ..

;,a,':.,:.I

,,a@:

h

.'.
..

-.~ ,

?!;%:!;.;:.
I

,

.

:a

.

i.$
..,

-

+.

I

File

Edit

1 C Back

View

Favorites

Tools

- + a m fl 1

Help

a~earch

Paper Work Reduction Act

'

Section 5(b) of the Radroad Unemployment Insurance Act (RUIA) requires the RRB to provide notice of claims for
benefits to base-year employers. Employer responses to these notices are voluntary. Fdure to provide mformation
about questionable claims for benefits, however, may aEect the amount that an employer is charged in benefits and the
employer's tax contribution rate under the RUIA.
The amount of time required for an employer to participate in the prepayment claims vedcation process varies
dependmg upon the extent to which the employer is able to use automated systems. We estimate the average
responding burden for employers to be:

1

Internet Form D - 4 K 2 minutes per response
hternet Form D - 4 E 2 minutes per response
These estimates are based on employer experience nationwide. The estimates include time for reviewing instructions,
obtainuzg needed data, and r e v i e w the completed responses. Federal agencies may not conduct or sponsor, and
respondents are not required to respond to a collection of information unless it displays a vahd OMB number. Ifyou
wish, send comments concertllng the accuracy of OM estimates or any other aspect of tlus program, includmg
suggestions for reducing reporbng time, to the Chief of Information Management, Radroad Retirement Board, 844 N.
Rush Street, Chicago, Ilhois 6061 1-2092 and the Office of Management and Budget, Paperwork Reduction Project
(3220-0171), Washulgton, DC 20503.

Thursday, Sep 25, 2008 01:21 PM