UI-41 (proposed) Supplemental Report of Service and Compensation

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

FORM APPROVED
OMB NO.3220-0070

( SOCIAL SECURITY NUMBER

SUPPLEMENTAL REPORT
OF SERVICE AND COMPENSATlON

EMPLOYEE'S NAME (FIRST, MIDDLE, LAST)

EMPLOYER

OCCUPATION

IBA#
DEPARTMENT

LOCATION
I

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 report or the
making of a false or fraudulent report can result in criminal prosecution or civil penalties, or both.
We estimate this form takes an average of 8 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 Chief of Information Resources Managemerit, Railroad Retirement Board,
844 North Rush Street, Chicago Illinois 60611-2092.

-

EMPLOYER'S REPORT
PLEASE FURNISH THE INFORMATION CHECKED
BELOW:

SERVICE MONTHS
Verify whether the employee worked o r 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 othewise
received. Do not include compensation over the
monthly amount shown.

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

(HOUR, DAY, MONTH, ETC.)

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

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

Certification: The information contained in this report is true and
correct to the best of my knowledge.

SIGNATURE
TITLE
REMARKS

DATE