SS Number Employee’s Name

REQUEST FOR

LIEN INFORMATION

REPORT OF SETTLEMENT

(See Important Notices Below)

United States of AmericaRailroad Retirement Board

To: Railroad Retirement Board

Office of Programs - OperationsAttn: Sickness and Unemployment BenefitsTelephone: (312) 751-4820Fax No. : (312) 751-7185

FOR RAILROAD USE ONLY

1. 2.

11.

4. 5. 7. 6. 8.

Information

Only

3.

Date of 

Injury

Railroad:City: State:

Telephone: ( ) Fax No.: ( )Name of Requestor: Date: / /

Date Completed: Date RetuComments:RRB Representative:

Return to

Work

“Yes” enter date.

“No” go to 11.

“Yes” enter date.

“No” go to 8. From To

Amount

Protected

&

Amount o

Settlemen

Settled * Pay for Time Lost

The RRB’s completed reply is confirmation of the amount of the RRB lien under section 12(o) of the Railroad Unemployment Insurance are provided ONLY for cases which have been settled. If payment is by check, return a copy of this form with your remittance, or be su9) and the Billing Doc ID (item 10) on your check.AMOUNTS DUE THE RRB UNDER SECTION 12(O) MUST BE RECEIVED WITHIN 30 DAYS AFTER THE DATE OF THE SETTLEMENT FINAL JUDGMENT. AMOUNTS THAT ARE NOT PAID WITHIN 30 DAYS ARE SUBJECT TO INTEREST CHARGES FROM THE DATE OF S

If any part of the settlement is apportioned to pay for time lost, show the exact months or other time period to which pay is allocated, or fax a copy of the If the lien amount shown is “Not Final,” the amount is valid for settlement and reimbursement purposes only if you inform the RRB within made. Otherwise, additional benefits may be paid to the employee. All settlements and final judgments must be reported to the RRB in 

of settlement or judgment. Notice may be made by facsimile using this form. The report of settlement is required to prevent additional bene

to provide Payor Code and Billing Doc ID information for the amount due the RRB under section 12(o) of the RUIA.

❏ Yes No ❏❏ Yes No ❏❏ Yes No ❏

❏ Yes No ❏

Yes No

❏ Yes No ❏❏ Yes No ❏

*

**

Notices:
INSTRUCTIONS

Please complete the following items and send this form via facsimile to the Railroad Retirement Board, Office Unemployment Benefits Section at (312) 751-7185.ITEM

Enter the employee’s first initial, middle initial and last name. Do not enter a partial name.

Enter the employee’s social security number.Enter the earliest date of occurrence of the injury for which a settlement is being made. If more than one inju

applicable dates.Check “Yes” if you are making an informational inquiry on this case and no settlement will be issued to the employee 

settlement will be issued to the employee once you receive a reply from the RRB.Please note that a second fax report is required if you make a settlement to the employee and your first re

Only.” Your second report is required to prevent additional benefit payments to the employee and to trig

statement for the amount due the RRB under section 12(o).Enter an “X” in the appropriate box to indicate whether the employee has returned to work. If the employee has returneshe returned to work.If settlement documents have been signed and a settlement concluded, enter an “X” in the “Yes” box and provide the dahas been agreed upon, but documents have not yet been signed or if settlement negotiations are proceeding, enter an ”X” 

If a settlement is made after obtaining information about the amount of the RRB’s lien, a second fax r

RRB within 5 days of the date of the settlement. The report of settlement is required to prevent additionemployee.If any part of the settlement is apportioned to pay for time lost, show the exact months or other time period to which p

the apportioned statement along with this form.Complete this section only if a settlement has been made. Enter the amount withheld from the settlement for rthe gross amount of the settlement. Information about the gross settlement amount is used to compute the period of tim

for which benefits are not payable on the basis of the same infirmity. Benefits are payable only after the amount of 

exceed the amount of the settlement. If the settlement exceeds $50,000, indicate only “In excess of $50,000.”

FOR RRB USE ONLY.

Enter the name of the railroad responsible for making the settlement, including the other identifying information as requ

1.2.3.4.5.6.7.8.11.

Paperwork Reduction Act/Privacy Act Notices–The RRB is authorized to collect the information requested on Form ID-3s uUnemployment Insurance Act (RUIA). The information is needed to determine the amount of sickness benefits reimbursable uBecause you are required to provide this information under section 9(a) of the RUIA, failure to complete and return this form could result We estimate this form takes an average of 3 minutes to complete, including the time for reviewing the instructions, getting the needed dform. Federal agencies may not conduct or sponsor, and respondents are not required to respond to, a collection of information unless it you wish, send comments regarding the accuracy of our estimate or any other aspect of this form, including suggestions for reducing 

Information Resources Management, Railroad Retirement Board, 844 Rush St., Chicago, Illinois.

Form ID-3s (3-09)

9. & 10.