Railroad Employment Questionnaire

Railroad Employment Questionnaire

MCS-MSSICS Screens

Railroad Employment Questionnaire

OMB: 0960-0078

Document [docx]
Download: docx | pdf

Screen facsimiles:

NHRR screen:

LnNo

0

1

1 2 3 4 5 6 7 7

234567890123456789012345678901234567890123456789012345678901234567890123456789

8

0

1

C

MCS TRANSFER TO: NH RAILROAD EMPLOYMENT NHRR


2

0

NH SSSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS SSSSSSSSSSS


3

l


4

u

RR EMPLOYEE: SSSSSSSSSS S SSSSSSSSSSSSSSSSSSSS SSN: SSSSSSSSSS


5

m

MONTHS WORKED IN RR AFTER 1936: XXX BEFORE 1937: XXX LAST 18 MOS (Y/N): X


6

n

EVER FILE FOR RRB RET/DISAB (Y/N): X IF YES, CLAIM NO: XXXXXXXXXXX


7

*

IF EMPLOYEE LIVING, REC'D RRB SICKNESS/UNEMPLOYMENT IN LAST 18 MOS (Y/N): X


8

o

IF RRB EMPLOYEE DECEASED, SURVIVOR EVER RECEIVE RRB BENEFITS (Y/N): X


9

n

EMPLOYEE WORK IN RR AFTER APPLYING FOR SOC SEC BENEFITS (Y/N): X


10

e


11


IF RR EMPLOYMENT IN LAST 18 MONTHS OR WORK AFTER FILING FOR SS BENEFITS:


12

r

RR EMPLOYER: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX


13

e

WORK LOCATION: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX


14

s

DEPT OCCUPATION: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX


15

e


16

r

IF CLAIMANT EVER RECEIVED RRB BENEFITS:


17

v

RR APPLICANT: SSSSSSSSSSSS S SSSSSSSSSSSSSSSSSSS CLAIM NO: XXXXXXXXXXX


18

e

RR EMPLOYEE NAME: XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX SSN: XXXXXXXX


19

d

RELATIONSHIP: XXXXXXXXXX


20


BENEFIT TYPE: X SELECT 1. MONTHLY 2. LUMP-SUM 3. RESIDUAL


21


HAS RRB NOTIFIED APPLICANT THAT RRB MAY BE AFFECTED BY ENTITLEMENT TO


22


SOCIAL SECURITY BENEFITS (Y/N): X


23



24


**************(Line 24 Reserved for Operating Systems Information)***********




























SPRR screen:

LnNo

0

1

1 2 3 4 5 6 7 7

234567890123456789012345678901234567890123456789012345678901234567890123456789

8

0

1

C

MCS TRANSFER TO: SP RAILROAD EMPLOYMENT SPRR


2

0

NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS SSSSSSSSSS


3

l


4

u

RR EMPLOYEE: SSSSSSSSSS S SSSSSSSSSSSSSSS SSN: SSSSSSSSS


5

m

MONTHS WORKED IN RR AFTER 1936: XXX BEFORE 1937: XXX LAST 18 MOS (Y/N): X


6

n

EVER FILE FOR RRB RET/DISAB (Y/N): X IF YES, CLAIM NO: XXXXXXXXXXX


7

*

IF EMPLOYEE LIVING, REC'D RRB SICKNESS/UNEMPLOYMENT IN LAST 18 MOS (Y/N): X


8

o

IF RRB EMPLOYEE DECEASED, SURVIVOR EVER RECEIVE RRB BENEFITS (Y/N): X


9

n

EMPLOYEE WORK IN RR AFTER APPLYING FOR SOC SEC BENEFITS (Y/N): X


10

e


11


IF RR EMPLOYMENT IN LAST 18 MONTHS OR WORK AFTER FILING FOR SS BENEFITS:


12

r

RR EMPLOYER: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX


13

e

WORK LOCATION: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX


14

s

DEPT OCCUPATION: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX


15

e


16

r

IF CLAIMANT EVER RECEIVED RRB BENEFITS:


17

v

RR APPLICANT: SSSSSSSSSSSS S SSSSSSSSSSSSSSSSSSS CLAIM NO: XXXXXXXXXXX


18

e

RR EMPLOYEE NAME: XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX SSN: XXXXXXXX


19

d

RELATIONSHIP: XXXXXXXXXX


20


BENEFIT TYPE: X SELECT 1. MONTHLY 2. LUMP-SUM 3. RESIDUAL


21


HAS RRB NOTIFIED APPLICANT THAT RRB MAY BE AFFECTED BY ENTITLEMENT TO


22


SOCIAL SECURITY BENEFITS (Y/N): X


23




24


**************(Line 24 Reserved for Operating Systems Information)***********





























CLRR screen:


LnNo

0

1

1 2 3 4 5 6 7 7

234567890123456789012345678901234567890123456789012345678901234567890123456789

8

0

1

C

MCS TRANSFER TO: SP RAILROAD EMPLOYMENT CLRR


2

0

NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS SSSSSSSSSS


3

l


4

u

RR EMPLOYEE: SSSSSSSSSS S SSSSSSSSSSSSSSS SSN: SSSSSSSSSS


5

m

MONTHS WORKED IN RR AFTER 1936: XXX BEFORE 1937: XXX LAST 18 MOS (Y/N): X


6

n

EVER FILE FOR RRB RET/DISAB (Y/N): X IF YES, CLAIM NO: XXXXXXXXXXX


7

*

IF EMPLOYEE LIVING, REC'D RRB SICKNESS/UNEMPLOYMENT IN LAST 18 MOS (Y/N): X


8

o

IF RRB EMPLOYEE DECEASED, SURVIVOR EVER RECEIVE RRB BENEFITS (Y/N): X


9

n

EMPLOYEE WORK IN RR AFTER APPLYING FOR SOC SEC BENEFITS (Y/N): X


10

e


11


IF RR EMPLOYMENT IN LAST 18 MONTHS OR WORK AFTER FILING FOR SS BENEFITS:


12

r

RR EMPLOYER: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX


13

e

WORK LOCATION: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX


14

s

DEPT OCCUPATION: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX


15

e


16

r

IF CLAIMANT EVER RECEIVED RRB BENEFITS:


17

v

RR APPLICANT: SSSSSSSSSSSS S SSSSSSSSSSSSSSSSSSS CLAIM NO: XXXXXXXXXXX


18

e

RR EMPLOYEE NAME: XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX SSN: XXXXXXXXX


19

d

RELATIONSHIP: XXXXXXXXXX


20


BENEFIT TYPE: X SELECT 1. MONTHLY 2. LUMP-SUM 3. RESIDUAL


21


HAS RRB NOTIFIED APPLICANT THAT RRB MAY BE AFFECTED BY ENTITLEMENT TO


22


SOCIAL SECURITY BENEFITS (Y/N): X


23




24


**************(Line 24 Reserved for Operating Systems Information)***********







File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleScreen facsimiles:
Author236746
File Modified0000-00-00
File Created2021-01-14

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