UI-41a (proposed) Supplemental Report of Compensation

Form Approved
OMB NO.3220-0070

U.S. Railroad ~etirementBoard
Office of 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 XXXX is needed to determine the amount of benefits payable
under the Railroad Unemployment Insurance Act (RLIIA) to the employee identified below. Once you have
completed the report, please return it to: Railroad Retirement Board, Office of Programs-Operations,
P.O. Box 10695, Chicago IL 60610-0695. Our authority for requesting this report is section 5(b) of the
RUIA. Failure to report or the making of a false or fraudulent report can result in criminal prosecution or civil
penalties, or both.
Papenwork Reduction Act Notice: We estimate this form takes an average of 8 minutes per response to complete,
including the time needed 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 the completion time, to Chief of Information
Resources Management, Railroad Retirement Board, 844 N. Rush Street, Chicago, IL 60611-2092.

Employee:
SS No.:
Address:

Enter the amount of compensation earned each
month, up to the monthly maximum of $X,XXX

Payroll No.: 4 o W X X X X X X >
ICC Code:
ER No.: ~XXXX>

JAN
FEB

Report for XXXX

'

MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
TOTAL

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