Form UI-1(03-04) Application for Unemployment Benefits and Employment Ser

United States of America
Railroad Retirement Board

Form Approved
OMB NO.3220-0022

Application for Unemployment Benefits
and Employment Service
Before completing this application, read the section Instructions for CompletingApplication for Unemployment Benefils and
Employment Service (Form UI-1) in the UB-10 booklet, which explains information needed to answer questions on this
application. PRTNT all answers in ink or use a typewriter. See the UB-10 booklet for the Privacy and Paperwork Reduction Act Notices.

Identifying Information
2. Social Security Number

1. Name (First, Middle Initial, Last)

4. Date of Birth
Month ( Day

3. Mailing Address (Include Apartment Number)

City, State, ZIP Code

5. Sex
Year

a Male
a Female

County

6a. Home/Cell/Message Telephone Number (Include Area Code)

6b. Work Telephone Number (Include Area Code)

Employment Information
7a. Last Railroad you worked for
b. Last Railroad Job Title (i.e., Clerk, Trainman, etc.)
c. Location of Last Railroad Job (City and State)

d. Why are you not now working for your last railroad employer? Check one:

a 7. Suspended
a 8. StrikeIWork Stoppage
a 9. Other, explain below

a 1. Laid Off/Furloughed/Abolished/l3umped a 4. Quit or Resigned
a 5. Retired
a 2. Extra Boarmart-Time
a 3. Sick or Injured
a 6. Discharged
Explanation
e. Have you quit or resigned any work
(railroad or other) during the last 3 years?

a Yes - Complete (1) & (2) below

a No - Go to Item 7f.

a Yes - Complete (1) - (4) below

a No - Go to Item 7g.

(1) Date resigned or quit and Employer's Name
(2) Date resigned or quit and Employer's Name
f. Are you discharged or suspended?
(1) Date of discharge or suspension period: From

To

a Yes
a Yes

(2) Are you seeking reinstatement to your job?
(3) Will you claim pay for time lost?

a No
a No

(4) Name of Union Official
Address

City, State, ZIP Code
Telephone Number (Include Area Code) (

1

g. Complete this item ONLY if you are unemployed due to a strike or work stoppage.
Name of your labor union

1

1

1

Refer to the instructions in Booklet UB-10 before com~letingItem 8.

~

8a. Date you want your first claim to begin.

b. Date you last worked for a railroad before date in Item 8a.
CONTINUE ON NEXT PAGE

Ul-1 (03-04)

9. Are you covered by a job protection plan guaranteeing you a certain amount of work or pay?

0

Yes

No

If "Yes," enter name of employer providing the guarantee, below.

I

I

Employer
-

- -

m Yes - Complete a. and b., below

No - Go to Item 11

Yes - Complete a. and b., below

No - Go to Item 12

Yes - Complete (1)-(5) and b., below

No - Go to Item 13

10. Have you been paid severance pay or a separation allowance?

I
-

- -

a. Date of separation
b. Name of employer that paid
11. Have you been self-employed in the past 2 years?

a. Type of self-employment
b. Date you were last self-employed
12. a. Have you been employed by a nonrailroad
employer in the past 2 years?
(1) Employer Name
(2) Employer Address (Street, City, State, ZIP Code)

I

(3) Date Last Worked

1

I

(4) Occupation

(5) Reason Not Working
b. Did you have other nonrailroad employment in the past 2 years?

, 13. Are you an active member of the National Guard or a military reserve unit?
School Information

0 Yes
0 Yes

1 14. a. Are you now attending school?

a Yes - Go to Item 15

I

IJ Yes

b. Do you plan to attend school in the next 6 months?

I

I

m No
O No

-

No Complete b., below

LI No

If "Yes," enter the month and year
- you
- will begin
- school

I

1

I

Other Benefits
15. Are you receiving social security benefits, military retirement
or retainer pay, or any other retirement or survivor benefits
provided by law?

I
1

a. Type of benefit(s)

Yes - Complete a.-c., below

No - Go to Item 16

b. Effective date

$
Direct Deposit Information

c. Monthly amount before deductions

I
1

16. Benefits are normally paid by Direct Deposit to your bank, savings and loan, credit union, or other financial institution. To
provide the information we need to correctly deposit your payments, attach a voided personal check and go to Item 17, or
call your financial institution for the information you need to complete Items a. through d. If you do not have a bank account,
or receiving your payments by Direct Deposit would cause you a hardship, go to Item e.

a. Routing Transit Number
c. Account Type:

1

1

Checking

b. Account Number

C] Savings

d. Name of Financial Institution
e.

a Check this box if you do not have a checking or savings account, or if Direct Deposit would cause you a hardship.
Certification and Signature

17. 1 certify that the information I have provided on this form is true, correct, and complete. I know that I must immediately
report to the Railroad Retirement Board any changes which might affect my entitlement to benefits. I understand that
disqualifications and civil and criminal penalties may be imposed on me for false or fraudulent statements or claims or for
withholding information to get benefits. I understand and agree to the requirements set forth in Booklet UB-10.

UI- 1 (03-04)

SIGNATURE
DATE
Mail your signed application immediately to the Railroad Retirement Board using the enclosed envelope.

1

1