ID-30K (05-17) Notice to Request Supplemental Information on Injury or

CURRENT

FORM APPROVED
OMB NO. 3220-0036

Claimant Name:
SS No.:
Notice to Request Supplemental Information on Injury or Illness
1. Did you receive a money settlement in payment of damages from any person or company who was liable for
your injury or illness?
Yes – Complete Items 2-6 and sign below.
No
Is a personal injury claim still being pursued?
Yes – Complete Items 2 and 3 and sign below.
No – Please explain

2. Enter name, address, telephone and facsimile (Fax) number of Insurance Company or payer.

Telephone
Number:

(

Fax
Number:

)

3. Policy No.:

(

)

Claim No.:

4. Date on which the payment was made for settlement:
5. Amount of the payment/settlement:

$

6. Amount withheld from the settlement to repay the lien:

$

I certify that the information I am giving is true, complete, and correct. I understand that criminal and civil
penalties may be imposed against me for false or fraudulent statements or for withholding information to
cause the payment of benefits by the RRB.
Signature:

Date:

Title:

Telephone:

(

)

Paperwork Reduction Act/Privacy Act Notices: The RRB is authorized to collect the information requested on this
form under Section 5(b) of the Railroad Unemployment Insurance Act (RUIA). The information is needed with respect to
sickness benefits paid under the Act. 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 5 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 the completion time, to:
Associate Chief Information Officer for Policy and Compliance, Railroad Retirement Board, 844 N. Rush Street, Chicago,
IL 60611-1275.

ID-30K (09-17)