(76) Form G-467, Parent's Certificate of Dependency and Support. This form is used by a claimant in furnishing information relative to a determination of status as a dependent parent of a deceased employee for the purpose of receiving a parent's annuity.

(77) Form G-468, Certificate of Responsibility of Minor Applicant. This is a form on which applicant for benefits who is still a minor is to provide information to support a request that benefits be paid without the appointment of a guardian and requires in addition, a statement by two adults that they are personally acquainted with the applicant and that to the best of their knowledge and belief the applicant's statements are true and complete.

(78) Form G-469, Certificate of Guardian-In-Fact or Person In Loco Parentis. Form to be used by a guardian-in-fact or a person in loco parentis of a minor with regard to an application of the minor for benefits and certifying that the benefits received would be used solely for necessities of the minor.

(79) Form G-661, Appeal From Decision Concerning Creditability of Service. This form is prescribed for filing an appeal from an initial decision of the Bureau of Retirement Claims with respect to a determination by that bureau that service claimed in connection with an application for annuity is not creditable because the employer is not covered by the Railroad Retirement Act.

(80) Form OE-1, Payroll Report Subordinate (Quarterly) for System Units. The form is for quarter-annual reports by system subordinate units of national-labor-organization "employers" of earnings by employees and of employer "contributions" remitted pursuant to the Railroad Unemployment Insurance Act; it shows also amounts of taxes paid pursuant to the Railroad Retirement Tax Act.

(81) Form OE-2, Payroll Report (Monthly) for System Subordinate Units. This form is similar to Form OE-1 except that it is for monthly reports.

(82) Form OE-2a, Payroll Report (Monthly) for Local Subordinate Units. This form is for monthly reports by local subordinate units of national-labororganization "employers" and of earn

ings by employees and show amounts of taxes paid under the Railroad Retirement Tax Act.

(83) Form OE-5, Service and Compensation Report by Labor Organization. This requires a report from covered labor organizations of the service and compensation of its covered employees.

(84) Form RL-13e, Notice to and Certification by a Disability Annuitant Upon Attainment of Age 65 of Relinquishment of Rights. This form is used to certify that a person receiving an annuity on the basis of physical disability and who has reached the age of 65, is not in the service of any employer under the Railroad Retirement Act or of the person by whom he was employed last before his annuity began to accrue and that he has relinquished all rights to return to the service of such an employer or person.

(85) Form RL-50, Letter and Questionnaire re Continuance of Disability Annuity Awarded after July 30, 1946. This form is to be used by annuitants receiving disability annuities to provide proof of continuance of the disability.

(86) Form RL-51, Report of Pay For Time Lost. This form is to be used by an employer to report payments to an employee for time lost.

(87) Form RL-52, Report Concerning Employment Relation. This form is used by an applicant for an annuity who was not in compensated service on August 29, 1935, to supply information concerning his employment status on that date.

(88) Form RL-66, Report of Use of Payments Made to Persons on Behalf of Annuitants and Pensioners. This form is for use in reporting how payments received in a representative capacity for incompetent beneficiaries are used.

(89) Form ES-1, Application for Employment Service. This form is to be used by unemployed persons in applying for placement by the employment service.

(90) Form ES-19b, Referral Card. This referral card is given to an applicant for employment service who is not a claimant for unemployment insurance benefits. It tells the applicant to report to a designated hiring official for work. The notice is to be left with the hiring office which is requested to complete the

card to show whether or not the appliI cant was hired and to return it to a designated Board office.

(91) Form ES-20a, Applicant's Referral Report. This form is to be used by a claimant for unemployment insurance to inform the Board field office of the results of his referral to a designated hiring official.

(92) Form ES-20b, Referral Card. This is a referral card given to a claimant for unemployment insurance benefits. It tells him to report to a designated hiring official for work. The notice is to be left with the hiring office which is requested to complete the card to show whether or not the applicant was hired and to return it to a designated Board office.

(93) Form ES-21, Referral Card-RRB to SES. This is a referral card given to an applicant for unemployment insurance benefits instructing him to report to the State Employment Service office for employment instructions. After entries have been made by the State Employment Service, or if he has not reported to the State Employment Service, he explains his reasons, and signs and dates the card and mails it to the Railroad Retirement Board.

(94) Form ES-21c, Report on Placement or Refusal of Referral or Job Offer. This is a form used by a State Employment Service representative to report the results of a referral of an applicant for unemployment insurance benefits to the Employment Service for placement.

(95) Form ES-107, Call-in - Card. This is a notice to an applicant for unemployment insurance benefits who has applied for employment service to appear in person at a designated place to discuss the possibility of employment. If the applicant does not report as directed, he is instructed to return the form furnishing information that he has good cause for not reporting. The form specifically states penalties for failure to comply with the instructions thereon.

(96) Form ES-110, Referral List. This is to list the individuals instructed to report to employer for an interview on job opening. The reverse side is to be completed by the employer to indicate whether the individuals were hired and date they are to begin work or reason they were not hired and is to be returned to a designated Board office.

(97) Form ID-5i, Report of Unemployment Insurance Claimant's Employment. Form to be used by non-railroad employers to report employment and earnings of a claimant who may have worked on days claimed as days of unemployment.

(98) Form ID-9a, Employer's Special Report of Compensation. This form is to be used by an employer to report compensation not previously reported to the Bureau of Wage and Service Records. This information is required in determining the benefit rights of an applicant for unemployment insurance benefits whose base year wages were earned in the employment of the employer.

(99) Form ID-9b, Special Report of Compensation for Service Under Contract. This form is to be used by a contractor who had contracts with an employer to report an employee's service and compensation.

(100) Form SI-1a, Application for Sickness Benefits. This form is to be used by an employee in applying for the form on which to claim sickness benefits. The completed form supplies information necessary to determine if the applicant is eligible to claim benefits and waives any existing "doctor-patient privileges" for the purpose of supplying medical information in support of his claim.

(101) Form SI-1b, Statement of Sickness. This form is a detachable part of Form SI-1a and is to be executed by an authorized person supplying medical information in connection with an employee's application for sickness benefits.

(102) Form SI-1c, Supplemental Information on Accident and Insurance. This form is to be used by a claimant of sickness benefits to supply information not shown on the sickness benefit application about the person or persons who may have been responsible for payment of damages to him.

(103) Form SI-1d, Pay Rate Report and Employer's Corrected Report of Pay Rate. This form is to be used by a claimant for sickness benefits to report the pay rates required to determine his daily benefit rates under the Railroad Unemployment Insurance Act. The pay rate report is then verified and, if necessary, corrected by the employer.

(104) Form SI-3, Claim for Sickness Benefits. This form is sent by the Board

to claimants for sickness benefits to inform the claimant of the registration period covered by the claim and to request information as to days of sickness claimed, days worked, and earnings. The form is to be returned to the office of the Board to which it is pre-addressed.

(105) Form SI-3a, Claim for Sickness Benefits. This form is the same as Form SI-3 but is sent to those claimants for sickness benefits whose statements of sickness indicate the need for additional medical information.

(106) Form SI-3b, Supplemental Doctor's Statement. This form is a detachable part of Form SI-3a and is to be executed by an authorized person to supplement information contained in Form SI-1b, Statement of Sickness, when additional information is desired.

(107) Form SI-5, Report of Payments to Employee Claiming Sickness Benefits under the Railroad Unemployment Insurance Act. This form is to be used by an employer or other person to report damages, pay for time lost, workmen's compensation or other payments made or payable to an employee claiming sickness benefits.

(108) Form SI-7, Supplemental Doctor's Statement. This form is to be filled out by a claimant's doctor to supply medical information needed to supplement a statement of sickness submitted under the Railroad Unemployment Insurance Act.

(109) Form SI-10, Statement of Authority to Act for Employer. This is a form to be used by a person in furnishing information concerning his authority when applying for sickness benefits under the Railroad Unemployment Insurance Act on behalf of an employee who is unable to sign documents and transact business in connection with obtaining such benefits.

(110) Form SI-34, Report of Physical Condition of Claimant Under Railroad Unemployment Insurance Act. This form is to be used by a medical examiner to report the physical condition of an applicant when it appears that he has been released from or rejected for work because of sickness and should therefore apply for sickness benefits.

(111) Form SI-62, Claim for Sickness Benefits to Employee But not Paid at

Death. This is the form to be used in making claim for sickness benefits due an employee but unpaid at his death.

(112) Form SI-101, Application for Maternity Benefits. This is the form to be used by a female employee in applying for a claim form on which to claim maternity benefits. The form provides for a statement by the employee of prior employment and of the birth or expected birth of a child; and also for a waiver of any existing "doctor-patient privilege” with respect to the maternity sickness for which the claim is made. This form is to be mailed, together with completed Form SI-104, to the Board.

(113) Form SI-103, Claim for Maternity Benefits. This is the form to be used in making claim for maternity benefits under the Railroad Unemployment Insurance Act.

(114) Form SI-104, Statement of Maternity Sickness. This form is to be executed by a doctor of medicine in connection with an application for maternity benefits, and is to be furnished by the applicant to the Board, upon execution, together with completed Form SI-101, Application for Maternity Benefits.

(115) Form UI-1, Application for Unemployment Benefits. This form is to be used by an employee in applying for unemployment benefits and provides for information in connection with employment service.

(116) Form UI-1a, Pay Rate Report and Employer's Corrected Report of Pay Rate. This form is given to a claimant for unemployment benefits to provide information of his employment and pay to be used in the determination of the claimant's daily benefit rate. The employer verifies and, if necessary, corrects the pay rate reported by the claimant.

(117) Form UI-1d, Pay Rate Report and Employer's Corrected Report of Pay Rate. This form is to be used by a claimant for unemployment benefits to provide information, supplemental or similar to that provided by Form UI-la, concerning the claimant's employment and rate of pay. The claimant's statements are to be verified by the employer.

(118) Form UI-3, Registration and Claim for Unemployment Benefits. This is a form for registering for days of unemployment and claiming unemployment insurance benefits, for providing

notice to the claimant of requirements upon him, and for statement to be certified to by the claimant.

(119) Form UI-3a, Explanation of Exceptions to Certification for Day of Unemployment. This form provides an opportunity for a full explanation of the reasons any statement to which a claimant has certified on Form UI-3 is not or may not be true for any particular day or days for which registration has been made.

(120) Form UI-9, Applicant's Statement of Employment and Wages. This is a form to be used in reporting service and compensation in connection with a claim for benefits under the Railroad Unemployment Insurance Act.

(121) Form UI-10, Request for Determination of Veteran Status under Title IV, Veteran's Readjustment Assistance Act of 1952. This form is to be used by applicants for railroad unemployment

benefits in applying also for benefits under Title IV of the Veteran's Readjustment Assistance Act.

(122) Form UI-84, Delayed Registration. This is a form upon which to make a delayed registration for a day or days of unemployment.

(123) Form UI-85, Appeal to the Board From Referee's Decision under Railroad Unemployment Insurance Act. This form is used to appeal to the Board from a decision of a referee on a claim for benefits under the Railroad Unemployment Insurance Act.

(124) Form UI-86, Appeal from Initial Determination under The Railroad Unemployment Insurance Act. This form is used to appeal from an initial decision denying benefits under the Railroad Unemployment Insurance Act.

[21 F. R. 4809, June 29, 1956] Prior Amendments 1950: 15 F. R. 6752, Oct. 6.

§ 208.1

Statutory provisions.

(a) The following-described individuals, if they shall have been employees on or after the enactment date, and shall have completed ten years of service, shall, subject to the conditions set forth in subsections (b), (c), and (d), be eligible for annuities after they shall have ceased to render compensated service to any person, whether or not an employer as defined in section 1 (a) (but with the right to engage in other employment to the extent not prohibited by subsection (d)):

(5) Individuals whose permanent physical or mental condition is such that they are unable to engage in any regular employment.

Such satisfactory proof shall be made from time to time as prescribed by the Board, of the disability provided for in paragraph 4 or 5 and of the continuance of such disability (according to the standards applied in the establishment of such disability) until the employee attains the age of sixty-five. If the individual fails to comply with the requirements prescribed by the Board as to proof of the continuance of the disability until he attains the age of sixty-five years, his right to an annuity by reason of such disability shall, except for good cause shown to the Board, cease, but without prejudice to his rights to any subsequent annuity to which he may be entitled. If before attaining the age of sixty-five an employee in receipt of an annuity under paragraph 4 or 5 is found by the Board to be no longer disabled as provided in said paragraphs his annuity shall cease upon the last day of the month in which he ceases to be so disabled. If after cessation of his disability annuity the employee will have acquired additional years of service, such additional years of

(2) Not more than twelve months before the filing of the application. (Sec. 2, 50 Stat. 309, 310, as amended; 45 U. S. C. 228b.)

CODIFICATION: § 208.1 was amended in the following respects by Board Order 55-89, 20 F. R. 3706, May 27, 1955:

1. In paragraph (a), the introductory text and subparagraph (5) were amended to read as set forth above.

2. Paragraph (b) was amended to read as set forth above.

3. In paragraph (c), subparagraph (2) was amended to read as set forth above.

§ 208.7 Annuities for employees. (a) Subject to the provisions of paragraphs (b) and (c) of this section, an individual who has been an employee on or after August 29, 1935, has completed 10 years of service, and has ceased to render service for compensation to any person, whether or not an employer under the act, is eligible for an annuity if:

(4) The physical or mental condition of the individual is such that he is unable to engage in any regular employment.

(b) No annuity shall be certified for payment to an individual until such time as he has filed with the Board a duly executed application form, has established by proof satisfactory to the Board that he possesses all the qualifications therefor, and, except for an individual whose eligibility for an annuity is determined in accordance with paragraph (a) (3) or (4) of this section, has relinquished rights to return to service as required by Part 216 of this chapter. In no case shall an annuity begin to accrue earlier than (1) twelve months prior to the date upon which the application therefor was filed with the Board, or (2) the day following the last day of the applicant's compensated service: Provided, however, That where such date falls on the thirty-first day of any month the annuity shall begin to accrue on the An first day of the following month. individual whose eligibility for an annuity is determined in accordance with