ID-4X (Proposed) Forms Letter, Advising of Service/Earnings Requirements

PROPOSED

Form Approved
OMB No. 3220-0025

U.S. RAILROAD RETIREMENT BOARD
Office of Programs - Operations
P.O. Box 10695
Chicago, Illinois 60610-0695
03-16-20

ID-4X (XX-XX)

408*69*7177*ID-4X*HAMBY*B*S*
B S HAMBY
750 SMITH RD
ONEIDA TN 37841-6884

REQ -

According to our records, you are not qualified for benefits under the
Railroad Unemployment Insurance Act based on your 2018 railroad earnings.
To be qualified for benefits in the general benefit year July 1, 2019
through June 30, 2020, you must have had railroad earnings of at least
$3900.00 in 2018, counting no more than $1560 for any month. If you
think our records are wrong and you believe you are qualified, complete
and return the enclosed Form UI-9.
Even though you are not qualified for benefits based on your 2018
earnings, you may now be eligible for benefits for which you would
normally become qualified on July 1, 2020. To be eligible for these
benefits you must have at least 10 years of railroad service, railroad
earnings of at least $4012.50 in 2019, and you must not have voluntarily
retired or reached age 65. If you believe that you meet these
requirements, please answer the questions below, sign your name in the
space provided and return this letter to the address shown above.
Sickness and Unemployment Benefits Section
1. In counting your total months of service, did you include military
service, if any?
Yes____ No____
If "Yes" give your entry date _______ and discharge date _______
2. Furnish the following information for each employer for whom you worked
or from whom you received vacation pay or pay for time lost in 2019.
If you need more space, use the other side of this notice.
Railroad: ___________________________________________________________
Occupation:__________________________________________________________
Place of Employment - City and State: _______________________________
List months of service in 2019: _____________________________________
PLEASE READ THE IMPORTANT NOTICES ON THE REVERSE SIDE OF THIS FORM.
I understand that civil and criminal penalties may be imposed on me for
false or fraudulent statements, or for withholding information to cause
payment of benefits by the RRB. I affirm that to the best of my
knowledge, the information I have given is true, complete, and correct.
Signature _______________________________________ Date __________
Enclosure:

Form UI-9

PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICES
The Railroad Retirement Board's authority for requesting this information
is Section 5(b) of the Railroad Unemployment Insurance Act. The
information requested on this form is needed to determine if you qualify
for benefits. You do not have to provide the information requested, but
if you fail to respond, we may not be able to pay you benefits.
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 completion time, to
Associate Chief Information Officer for Policy and Compliance, Railroad
Retirement Board, 844 N. Rush St., Chicago, IL 60611-1275.