ID-5I (xx-xx) Form Letter; Request for Employment Information

FORM APPROVED
OMB NO. 3220-0025

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

PROPOSED
OFFICE HOURS: M-T-TH-F 9:00 AM TO 3:30 PM
WEDS. 9:00 AM TO 12:00 PM - CLOSED FEDERAL HOLIDAYS

In reply refer to

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
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

Proposed Form

- 2

Form Approved OMB No: 3220-0025

Name:
Employer:

SSN:

Enter the earnings in the appropriate box below for each day of employment between SEP 2019 and MAR 2020.

OCCUPATION: __________________________________________________________________________
EMPLOYED FROM: __________________________TO _____________________________
REASON FOR TERMINATION (IF NOT EMPLOYED):
____________________________________________________________________________
EMPLOYER CERTIFICATION:

SIGNATURE

THE INFORMATION IN THIS REPORT IS CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.

TITLE

OFFICIAL TO CONTACT FOR
ADDITIONAL INFORMATION:

DATE

(
NAME/TITLE

)

TELEPHONE NUMBER
ID-5I (xx-xx)