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pdfPROPOSED
SI-3 (XX-XX)
Form Approved
OMB 3220-0039
birect Deposit - If you are not currently receiving payments by Direct Deposit and wish to sign up, please contact your local RRB office.
Record of Recent Benefit Payments:
Type
Amount
SI
$192.00
$640.00
SI
-----$640.00
SI
....,.,,...,..__.,
.
Date Approved
02/25/2010
02/05/2010 --02/05/2010
Claim Beginning
01/2512010
01/11/2010
12/28/2009
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Privacv Act Notice
Computer Matching and Privacv Protection Act Notice
Paper..vork Reduction Act Notice
Nondiscrimination on the Basis of Disabilitv
Fraud and Abuse Hot Line
Claims:
The following claim(s) are available for completion: If you do not wish to file on the Internet, please file the paper claims we mailed to you. Do not file both a paper and Internet
claim for the same claim period. To begin your claim for sickness benefits, click on one of the claim periods listed below.
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Claim(s) that are currently available for completion:
CIaim(s) Available for Completion
___........=07=1i =/5 2==010= _through 07/28/2010
DATE MADE AVAILABLE
---8/4/2010
To return to the Benefit Online (Mainline) Services Menu to do additional private, secure business with us, click here.
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Paperwork Reduction Act Notice
To receive unemployment benefits, you must complete an application and claim form(s). Estimates of how long we think ii takes to complete these
forms are shown below. The estimates include time for reviewing the instructions, getting the needed information, and reviewing the completed form
Federal agencies may not conducl or sponsor, and respondents are not required to respond to, a collection of information unless it displays a vafid
0MB number. If you wish, send comments regarding the accuracy of our estimates or other aspects of the forms, including suggestions for reducing
completion time, to the Associate Chief Information Officer of Policy & Compliance, Railroad Retirement Board, 644 North Rush street, Chicago,
llfinois 60611-1275. Be sure to include the form title with your comments.
Form
Number
Title
Estimated
Completion Time
(Minutes)
S1-3
Claim for Sickness Benefits (3220-0039)
5
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se| File Type | application/pdf |
| File Title | KM_284e-20170217151825 |
| File Modified | 2020-08-20 |
| File Created | 2017-02-17 |