ES-21 (11-07) Referral to State Employment Service

Form Approved
OMB No. 3220-0057

U.S. RAILROAD RETIREMENT BOARD
BIS • Information Resources Management
844 North Rush Street

Chicago, IL 60611·2092

In reply refer to SS No.:

!

Report to state Employment Service Office at:

•

Report on or before:

Please report in person to the State Employment Service (SES) office shown above and apply for work to which you
may be referred by that office.
Instructions for Completing Part A and Part S
• When you report to the SES office, give this notice and the postage paid envelope to the SES representative.
• Have the SES representative complete Item 1 below and return this page to you.
• You must sign and date Item 3 then use the postage due envelope to return this page to our address shown above.
• The SES representative will complete and return the next page (Part S) in the postage paid envelope.
• If you do not report to the SES office, you must complete Items 2 and 3 and return this notice to us no later than the
date you are to report.
NOTE: If you fail to report to the SES office or to comply with the office's instructions, you may be disqualified from
receiving unemployment benefits for a period of 30 days.

REFERRAL TO STATE EMPLOYMENT SERVICE (PART A)
Item 1

(To be completed by State Employment Service Office. Return this page to the applicant and then go to
PART S on the next page.)
Date applicant reported:
SES Office Stamp:

Item 2

(To be completed by applicant) If you do not report to the SES office, enter reason:

Item 3
Your Signature

Date

PAPERWORK REDUCTION ACT/PRIVACY ACT NOTICE

The information requested on this form will be used by t Railroad Retirement Board (RRB) to determine your eligibility for
unemployment benefits. The RRS's authority for reques . this information is section '5(b) of the RailroadUnempToyment
Insurance Act. Although you are not requirea to provide t
information, failure to do so may prevent payment of benefits to
you.
We estimate this form takes less than 1 minute to complete. including the time needed for reviewing the instructions, getting
the needed data, and reviewing the completed form. Federal agencies may not conduct or sponsorhand respondents are not
required to respond to. a collection of information unless it displays a valid OMB number. If you wis , send comments
regarding the accuracy of our estimate or any other aSRect of this form. including suggestions for reducirlQ the completion
time1 to: Chief of Information Resources Management, Railroad Retirement Board, ff44 N. Rush Street. Chicago, It.:

60611-2092.

ES-21 (11-07)