Pay for Time Lost

(Exact Days) Amount Due RRB and Billing

Doc ID

Yes (If Requested)

SS Number

CTION 2(F)

ION

es Below)

FORM APPROVEDOMB NO. 3220-0036

To: U.S. Railroad Retirement Board

Office of Programs – OperationsAttn: Claims Adjustment & Settlement SectionTelephone: (312) 751-4820Fax No. : (312) 751-7185

RRB

USE

ONLY

FOR RAILROAD USE ONLY

2.

3. 4. 6. 5. 7.

9.

ID:ID:ID:ID:

10.

State:

Date: / /

Date Completed: Date Returned:Comments:RRB Representative:

Guarantee Information Only

Payor Code:

From To Month Year No

Amount

of

Payment

Date

of

Payment

ent Board’s (RRB) completed reply is confirmation of the amount due under section 2(f) of the Railroad Unemployment Insurance Act.

eport is required if you make a payment to the employee and this request is for “Information Only.” The subsequent report is needed to

reimbursement due the RRB, to prevent additional benefit payments and to trigger the release of a billing statement for the amount due.

re provided upon request, but only for claims which have been settled, i.e., cases in which item 7 is checked “No.” If reimbursement will

 statement, return a copy of this form with your remittance or be sure to show your Payor Code and the Billing Doc ID on your remittance.

Form ID-3u (3-09)

UNDER SECTION 2(F) MUST BE RECEIVED WITHIN 30 DAYS AFTER THE DATE OF PAYMENT TO THE EMPLOYEE.

PAID WITHIN 30 DAYS ARE SUBJECT TO INTEREST CHARGES FROM THE DATE OF PAYMENT.
INSTRUCTIONS

ng items and send this form via facsimile (fax) to the Railroad Retirement Board, Office of Programs - Claims

ection at (312) 751-7185.

rst initial, middle initial and last name. Do not enter a partial name.

ocial security number.

ich the employee has been awarded pay for time lost. For example, enter “June 3, 5, and 8, 1997.” If the days in

us, enter the first and last day of the period, e.g., May 5, 1997 – June 24, 1997.

he year for which the employee is being paid a monthly wage guarantee or allowance. If a guaranteed wage will

ne month, enter each month on a separate line.

t of the monthly guarantee or pay for time lost award to be paid to the employee. Under section 2(f) of the Act,

reimbursement of the amount of benefits paid for days in the same period for which the employee is paid for time

the guarantee or pay for time lost award, whichever is less. It is important to complete this section so that the

he amount due is less than the amount of benefits paid for the period.

dy been made to the employee, enter the date of the payment. In most cases, benefits due to an employee for the

 will be stopped, thereby reducing the amount of reimbursement due the RRB.

making an informational inquiry on this case and no payment will be issued to the employee at this time. Check

be issued to the employee once you receive a reply from the RRB.

econd fax report is required if you make a payment to the employee and your first request was for 

 Your second report is required to prevent additional benefit payments to the employee and to

f a billing statement for the amount due the RRB under section 2(f).

 railroad responsible for making the settlement, including the other identifying information as requested (i.e.,

elephone and fax numbers, location of the office making the inquiry and the date).

Privacy Act Notices–The RRB is authorized to collect the information requested on Form ID-3u under section 5(b) of the

urance Act (RUIA). The information is needed to determine the amount of unemployment benefits reimbursable 

A. Because you are required to provide this information under section 9(a) of the RUIA, failure to complete and return 

e or imprisonment or both.

an average of 3 minutes to complete, including the time for reviewing the instructions, getting the needed data, and

 Federal agencies may not conduct or sponsor, and respondents are not required to respond to, a collection of information

B number. If you wish, send comments regarding the accuracy of our estimate or any other aspect of this form, including

pletion time, to the Chief of Information Resources Management, Railroad Retirement Board, 844 Rush St., Chicago,