UI-41a (10-01) Supplemental Report of Compensation

Form Approved
OMB. No. 3220-0070
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U.S. Railroad Retirement Board
Office o f Programs
Operations
P.O. Box 10695
Chicago, Illinois 60610-0695

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In Reply Refer To
ER No.

SUPPLEMENTAL REPORT OF COMPENSATION
A report of compensation for calendar year
is needed for the employee identified below. The
report is needeg to determine the amount o f benefits payable to the employee under the Railroad
Unemployment Insurance Act (RUIA). Our authority for requesting this report is section 5(b1 o f the
RUIA Failure to report can result in a fine or imprisonment or both (45 USC 3591.
Paperwork Reduction Act Notice: 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. W e estimate that this form takes an average of 8 minutes to
complete, including the time for reviewing the instructions, obtaining the needed data, and reviewing the completed f o r m If you
wish, send comments regarding the accuracy of our estimate or any aspects of this. form. including suggestions for reducing
completion time, to Chief of Information Management Railroad Retirement Board, 844 N. Rush Street, Chicago, Illinois 606 1 1-2092

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Employee
SS No.

Report For
For each month, enter the amount of
compensation earned up to
per month

Address
Payroll No.
ICC Code
ER No.

JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
TOTAL

Return Report To:
Railroad Retirement Board
Office o f Programs Operations
P.O. Box 10695
Chicago, Illinois 606 10-0695

Signature:
Title:
Railroad:
Date:
Form UI-41A

(10-61 )