ID-3S-1 (03-09) Lien Information Under Section 12(o) of the RUIA

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United States of America
Railroad Retirement Board

UEN INFORMATION
UNDER SECTION 12(0)
OF THE
RAILROAD UNEMPLOYMENT
INSURANCE ACT
(See Important Notices Below)

3.

Form Approved
OMB No. 3220-0036

1. Please Indicate
From:fTo:

(Name of Inquirer)

(Phone Number)

I

(FaCSi~ile Number)

I

U.S. Railroad Retirement Board
Office of Programs - Operations
Attn: Claims Adjustment and Settlement Section
844 North Rush Street
Chicago, Illinois 60611-2092
Telephone Number: (312) 751-4820
Facsimile Number: (312) 751-7185
6.

5.

4.

Employee's Name

I

Date

(Law Firm/Insurance Company)

2. Please Indicate
To:/From:

Social Security Number

Date of Injury

RRB Use Only
Lien Amount

*Final

D
D
D
D
D
D
Notices:

I

Yes
No

Yes
No

Yes
No

This is in response to your inquiry about benefits recoverable under section 12(0) of the Railroad Unemployment Insurance Act (RUIA). The
Railroad Retirement Board's (RRB) completed reply is confirmation of the amount of the RRB's lien. No confirmation letter will be provided.
* 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 the settlement has been made. Regulations require that you notify the RRB within 5 days of the settlement or judgment and that
you pay the RRB the amount withheld to satisfy the lien within 30 days of the date of the settlement or judgment. Amounts that are not
paid within 30 days are subject to interest charges from the date of the settlement or judgment. If we do not receive such a notice within 5
days, the amount recoverable may be increased by the payment of additional benefits. After 5 days, we will provide, upon request, an updated
figure on the amount of benefits paid.

If a case has reached a settlement, the RRB should be reimbursed for the amount of our lien. The amount of reimbursement should be sent in the
form of a check or money order made payable to the Railroad Retirement Board. Please show the employee's social security number and the
date of the settlement on your remittance.
Attorney's fees - The RRB's regulations (20 CFR 341.9) provide that the RRB shall not be liable for the payment of any attorney's fee or other
expenses incurred in connection with any personal-injury claim.
Statutory lien - The RRB does not have a subrogation claim, but does have a right to reimbursement protected by a Federal statutory lien set
forth in section 12(0) ofthe RUIA (45 U.S.C. 362(0)).
(Date Returned)
(RRB Representative)

ID-3S-1 (03-09)

INSTRUCTIONS

Please complete Items 1-5 and send this form via facsimile (fax) to the Railroad Retirement Board, Office of Programs - Claims Adjustment and
Settlement Section at (312) 751-7185.
ITEM
1. Circle the appropriate sender designation and enter the name of the law firm or insurance company making the inquiry, including the other
identifying information as requested (Le., name of the inquirer, telephone and fax numbers and the date). For example, if the Form 10-3S-1 is
being faxed to the Railroad Retirement Board, circle "From:" and complete the remaining items.
2. Circle the appropriate receiver designation. For example, if the Form 10-3S-1 is being faxed from the Railroad Retirement Board, circle
"From:." Item 1 must be addressed to the inquirer.
3. Enter the employee's name beginning with the first

middle

and

last name. Do not enter a partial name.

4. Enter the employee's social security number.
5. 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 all
applicable dates.
6. FOR RRB USE ONLY.

Paperwork Reduction Act/Privacy Act Notices - The Railroad Retirement Board is authorized to collect the information requested on Form
10-3S-1 under section 5(b) 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 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 conductor 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 the Chief of Information Resources Management, Railroad Retirement Board, 844
North Rush Street, Chicago, Illinois 60611-2092.

ID-38-1 (03-09)