ID-3S-1 (08-17)

LIEN INFORMATION

UNDER SECTION 12(O)

OF THE

RAILROAD UNEMPLOYMENT

INSURANCE ACT

(See Important Notices Below)

1. Please Indicate

From:/To: Date / / 

2. Please Indicate

 To:/From:

U.S. Railroad Retirement Board

Office of Programs - Operations

Attn: Claims Adjustment and Settlement Section

844 North Rush Street

Chicago, Illinois 60611-1275

Telephone Number: (312) 751-4820

Facsimile Number: (312) 751-7185

(Law Firm/Insurance Company)

(Name of Inquirer)

(Phone Number) (Facsimile Number)

3.

Employee's Name

4.

Social Security Number

5.

Date of Injury

6.

RRB Use Only

Lien Amount

*Final

 Yes

 No

 Yes

 No

 Yes

 No

Notices: This is in response to your inquiry about benefits recoverable under section 12(o) of the Railroad Unemployment Insurance Act (RUIA). The 

Railroad Retirement Board's (RRB) completed reply is confirmation of the amount of the RRB's lien. No confirmation letter will be provided.

* If the lien amount shown is "Not Final," the amount is valid for settlement and reimbursement purposes ONLY if you inform the RRB within 5 

days that the settlement has been made. Regulations require that you notify the RRB within 5 days of the settlement or judgment and that 

you pay the RRB the amount withheld to satisfy the lien within 30 days of the date of the settlement or judgment. Amounts that are not 

paid within 30 days are subject to interest charges from the date of the settlement or judgment. If we do not receive such a notice within 5 

days, the amount recoverable may be increased by the payment of additional benefits. After 5 days, we will provide, upon request, an updated 

figure on the amount of benefits paid.

If a case has reached a settlement, the RRB should be reimbursed for the amount of our lien. The amount of reimbursement should be sent in the 

form of a check or money order made payable to the Railroad Retirement Board. Please show the employee's social security number and the 

date of the settlement on your remittance.

Attorney's fees - The RRB's regulations (20 CFR 341.9) provide that the RRB shall not be liable for the payment of any attorney's fee or other 

expenses incurred in connection with any personal-injury claim.

Statutory lien - The RRB does not have a subrogation claim, but does have a right to reimbursement protected by a Federal statutory lien set 

forth in section 12(o) of the RUIA (45 U.S.C. 362(o)).

(RRB Representative) (Date Returned)

United States of America

Railroad Retirement Board

Form Approved 

OMB No. 3220-0036
ID-3S-1 (08-17)

INSTRUCTIONS

Please complete Items 1-5 and send this form via facsimile (fax) to the Railroad Retirement Board, Office of Programs – Claims Adjustment and 

Settlement Section at (312) 751-7185.

ITEM

1. Circle the appropriate sender designation and enter the name of the law firm or insurance company making the inquiry, including the other 

identifying information as requested (i.e., name of the inquirer, telephone and fax numbers and the date). For example, if the Form ID-3S-1 is 

being faxed to the Railroad Retirement Board, circle "From:" and complete the remaining items.

2. Circle the appropriate receiver designation. For example, if the Form ID-3S-1 is being faxed from the Railroad Retirement Board, circle 

"From:." Item 1 must be addressed to the inquirer.

3. Enter the employee's name beginning with the first initial, middle initial, and full last name. Do not enter a partial name.

4. Enter the employee's social security number.

5. Enter the earliest date of occurrence of the injury for which a settlement is being made. If more than one injury is being settled, enter all

applicable dates.

6. FOR RRB USE ONLY.

Paperwork Reduction Act/Privacy Act Notices – The Railroad Retirement Board is authorized to collect the information requested on Form 

ID-3S-1 under section 5(b) of the Railroad Unemployment Insurance Act (RUIA). The information is needed to determine the amount of sickness 

benefits reimbursable under section 12(o) of the RUIA. 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 3 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 North Rush Street, Chicago, Illinois 60611-1275.