Form ID-5R (SUP) (12-00 ID-5R (SUP) (12-00 Report of Employees Paid RUIA Benefits for Every Day in

REPORT OF EMPLOYEES P A I D RUIA BENEFITS FOR EVERY DAY
I N MONTH REPORTED AS MONTH OF CREDITABLE SERVICE
EMPLOYER : 1 6 2 1

-

BURLINGTON NORTHERN SANTA FE R

EMPLOYEE
ADDRESS ( C I T Y AND STATE)

SS NUMBER
,

SUMNER

PAYROLL I D NO
XCC OCC CODE

CALENDAR YEAR

* FOR *
*BD USE*
*
*

FULLY CLAIMED MONTHS
EARNINGS REPORTED

-

1999

FOR EMPLOYER USE

........................................

-80- 1166

WA
FEE MAR

AUG SEP
APR MAY 3UN
DEC

DONNELLSON

.,

-52-4435

.

LACROSSE

WI

TAPPEN

ND

MAR APR

EMPLOYER CERTIFICATION:
SIGNATURE
FORM I D - 5 R (SUP)

THE INFORMATION I N T H I S REPORT I S CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.
TITLE

(12-00)

O F F I C I A L CONTACT: NAME

DATE
TELEPHONE NO.

(

1