ID-5I (Proposed) Form Letter, Request for Employment Information

PROPOSED

Form Approved
OMB No. 3220-0025

UNITED STATES OF AMERICA

RAILROAD RETIREMENT BOARD
POLICY & COMPLIANCE
844 N. RUSH STREET

CHICAGO, IL 60611-1275
WWW.RRB.GOV
OFFICE HOURS: M-T-TH-F 9:00 AM TO 3:30 PM
WEDS. 9:00 AM TO 12:00 NOON - CLOSED FEDERAL HOLIDAYS

PHONE NUMBER:

1-312-751-4826

March 24, 2020

,
In reply refer to
SS No.:
Name:

REQUEST FOR EMPLOYMENT INFORMATION
Our files indicate that the individual named above has been employed by you. This individual claimed
benefits under the Railroad Unemployment Insurance Act, a Federal law. Since these benefits are
paid on a daily basis, we need to know the exact days the individual worked for you. This
request involves a routine check of our records and is not an indication that the employee has filed
improper benefit claims.
Please furnish the information requested on the next page about each day worked OR provide the
information requested by submitting a computer printout or other company records which clearly show
the employee's daily earnings. Regardless of how you provide the information, please complete and
sign the Employer Certification at the bottom of the next page and return both pages of this form in
the enclosed postage-paid envelope. Our authority for requesting this information is shown below.
Railroad Retirement Board
Enclosure
AUTHORITY FOR REQUEST
The Railroad Retirement Board (RRB) is a United States Government agency and is responsible for the
administration of the Railroad Unemployment Insurance Act (45 U.S.C. 351 et. seq.). This Act provides for
payment of unemployment and sickness benefits to qualified employees in the railroad industry.
Our authority for requesting information is contained in provisions of the Railroad Unemployment Insurance
Act (45 U.S.C. 355(b), 359(a) and 362(a)). Although the Act gives the RRB the authority to compel
disclosure through use of a subpoena, the RRB's experience has been that employers voluntarily release
earnings information when they know that the RRB uses that information only for the purpose of verifying a
claim for benefits.
The RRB realizes that many companies have adopted policies regarding disclosure of personal information
needed for proper administration of the Railroad Unemployment Insurance Act. Information that the RRB
acquires about a person is protected from disclosure except as provided by law.
PAPERWORK REDUCTION ACT NOTICE
We estimate this form takes an average of 15 minutes to complete, including the time for reviewing the instructions,
getting the needed data, and reviewing the completed form. Federal agencies may not conduct 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 Associate Chief Information Officer for Policy and Compliance, Railroad Retirement
Board, 844 N. Rush St., Chicago, IL 60611-1275.

ID-5I (xx-xx)

UNITED STATES RAILROAD RETIREMENT BOARD - 2

Form Approved OMB No. 3220-0025

Name:

SS No.:

Enter the earnings in the appropriate box below for each day of employment between

DAYS OF
MONTH
1

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

and

SEP

.

OCT

NOV

DEC

2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
OCCUPATION:

__

EMPLOYED FROM: ______________________ TO _______________________
REASON FOR TERMINATION (if not now employed): _________________________________________________________________________
EMPLOYER CERTIFICATION: THE INFORMATION IN THIS REPORT IS CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.
__________________________________________________ _____________________________________ __________________
SIGNATURE
TITLE
DATE
OFFICIAL TO CONTACT FOR
ADDITIONAL INFORMATION: ___________________________________________________________ (______)____________________
NAME/TITLE
TELEPHONE NUMBER

ID-5I (xx-xx)