Information Collection

Certification Regarding Rights to Unemployment Benefits

IC 33878 under ICR 200708-3220-002 · OMB 3220-0079.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0079 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form UI-45 (08-04) Claimant's Statement - Voluntary Leaving of Work Certification Regarding Rights to Unemployment Benefits	Form
Form UI-45 (proposed) Claimant's Statement - Voluntary Leaving of Work Certification Regarding Rights to Unemployment Benefits	Form
UI-45 (08-04) Claimant's Statement - Voluntary Leaving of Work Form UI-45 (08-04).pdf	Form
UI-45 (proposed) Claimant's Statement - Voluntary Leaving of Work Form UI-45 (proposed).pdf	Form

IC Title:

Certification Regarding Rights to Unemployment Benefits

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 320.5

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	UI-45 (08-04)				No		Paper Only
Form	UI-45 (proposed)				No		Paper Only

Line of Business: Income Security

Subfunction: Unemployment Compensation

Privacy Act System of Records

Title: RRB-6, Unemployment Insurance Records

FR Citation: 40 FR 36269

Number of Respondents: 1,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,950	-950	2,900
Annual IC Time Burden (Hours)	408	-79	487
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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