Form UI-41 (10-00) UI-41 (10-00) Supplemental Report of Service and Compensation

FORM APPROVED
OMB NO.3220-0070

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

I SOCIAL SECURITY NUMBER
SUPPLEMENTAL REPORT
OF SERVICE AND COMPENSATION

I

EMPLOYEE'S NAME (FIRST, MIDDLE, LAST)
OCCUPATION

EMPLOYER

/BA#
LOCATION

DEPARTMENT
PAYROLL NAME, IF DIFFERENT THAN SHOWN ABOVE

Completion of this report is required under provisions of section 5(b) of the Railroad Unemployment Insurance Act (RUIA). The
purpose of the report is to obtain service and compensation information needed to determine eligibility for benefits under the
RUIA. Failure to complete this report can result in a fine or imprisonment or both (45 USC 359).

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EMPLOYER'S REPORT
PLEASE FURNISH THE INFORMATION REQUESTED
BY THE BOXES CHECKED BELOW:

SERVICE MONTHS
Verify whether the employee worked or was paid
compensation for the months checked. Enter "C" for
each month that service is verified.

SERVICE MONTHS AND COMPENSATION
FOR YEAR(S):
Enter the amount of the employee's compensation
for each month worked or where pay was otherwise
received. Do not include compensation over the
monthly amount shown.

RATE OF PAY FOR LAST DAY WORKED IN
CALENDAR YEAR:
PER
AMOUNT

I DO NOT INCLUDE MONTHLY COMPENSA-I-ION
YEAR
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC

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(HOUR, DAY, MONTH, ETC.)

TOTAL
COMPENSATION

I SIGNATURE

RETURN THIS FORM TO:
RAILROAD RETIREMENT BOARD
SICKNESS AND UNEMPLOYMENT
BENEFITS SECTION
PO BOX 10695
CHICAGO, ILLINOIS 60610-0695

TITLE

I DATE

PAPERWORK REDUCTION ACT NOTICE
We estimate this form takes an average of 8 minutes to complete, including the tine for reviewing the instructions, obtaining 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 aspects of this
form, including suggestions for reducing completion time, to Chief of Information Management, Railroad Retirement Board, 844 North Rush Street,
Chicago Illinois 6061 1-2092.