UI-3 (04-04) Claim for Unemployment Benefits

U.S. RAILROAD RETIREMENT BOARD

Telephone:
Hours:

INSTRUC'I'IONS
1. Print all responses neatly in ink.
2. Make sure your name and address are correct. If they are not, enter the correct information in ltem 4.

3. Read carefully the section titled "Instructions for Completing Claims for Unemployment Benefifs (Form UI-3)" in the
UB-10 booklet before completing the claim form on the next page.
4. After completing the claim form mail it in the envelope provided. If you need assistance, telephone the RRB office
identified above.
5. Waitinq PeriodlBenefit Pavments - If this is your first claim in a period of unemployment and you have not previously
satisfied the benefit year waiting period requirement, benefits will be paid to you for your days of unemployment over 7
in the period. Otherwise, benefits are normally payable for the number of days of unemployment over 4 in each claim
period. Exception: There are special rules for payment of benefits for days of unemployment due to a strike or work
stoppage.
Allow 15 calendar days from the date you mail your claim for a payment to be received. If you do not receive a
payment or other notice within 15 days, contact your local RRB office for information about the status of your claim.
6. Rest Davs - Use an " X in ltem 1 of your claim to show your normal rest days, unless you worked or otherwise
received pay from either a railroad or nonrailroad employer for the day, or unless you were sick o r otherwise
unable or not available for work on that day.

IMPORTANT: Promptly return your claim form to the RRB after the last day of the claim period, or you may lose
benefits. The time limit for filing your claim is 15 days from the last day of the claim period or 15 days from the
date the form was mailed to you, whichever is later. If your claim is late because of circumstances beyond your
control, enclose an explanation.
RRB HelpLine - For information about the benefits paid to you or to check on the status of your application or claim form,
call the RRB HelpLine at 1-800-808-0772.
DO NOT SIGN, DATE, OR MAIL THE CLAIM FORM BEFORE THE LAST DAY OF THlS CLAIM PERIOD.
(REFER
TO BOOKLET
UB-10 FOR PRIVACY
ACTAND PAPERWORK
REDUCTION
NOTICES
AND FURTHER INSTRUCTIONS ON COMPLETING THlS FORM.)
COMPLETE AND KEEP FOR YOUR RECORDS
Beginning Date of this Claim

Date Mailed to. RRB

FORM UI-3 (04-04)

UNITED STATES OF AMERICA
RAILROADRETIREMENT BOARD

I

FORM APPROVED

OM6 3220-0022

CLAIM FOR UNEMPLOYMENT BENEFITS
la.

This claim is for unemployment benefits for the 14 consecutive days shown below. To claim benefits, mark the box under each
date with the appropriate code (X, E, P, or 0).
X Claimed day of unemployment (Including rest days); E Day employed; P - Vacation or holiday pay; 0 - Day not claimed, other reason
This claim is for

-

-

through
b.

2

Mark each box with X, E, P, or 0
Enter the gross amount of wages andlor other pay (before deductions) that you
received or will be paid for days in this period. Do not include RRB benefits or
$
oavments received under a suoolemental unemolovment benefit olan. This item
must be completed i f you erhered " E or "P'"fo; any day in lt'em la.
a. Name of last railroad employer
b. Last railroad job (show job title, e.g., clerk, trainman, etc.)

I

Reason you are not working (check one box)
[7 1. Laid Off [7 2. Extra BoardIPart Time q3. Sick or Injured q 4. Quit or Resigned
5. Retired
6. discharged
7. Suspended
8. Strikework Stoppage
9. Other (Explain below)
Explanation:
Return your claim to the address below
4. If your name or address is incorrect, print changes below
C.

3.

5a. Have you worked for a nonrailroad employer since your last day of railroad work?
YES - Complete ltems b.-d., below
NO - Go t o ltem 6
b. Enter employer name and address.
c. Enter date last worked before this claim.
d. Enter your reason for not working.
6a. Did you work in train and engine service or passenger service during this period?
q YES -Complete ltems b.-c., below
NO - Go t o ltem 7
b. Enter the miles or hours worked during this 14-day claim period. Include miles or hours earned for regular pay, premium pay,
overtime, and deadheading. + Miles
Hours
c. Enter the dates in this period on which you did not work because of a layover or stand-by rule, mileage restriction, or because you
missed a turn in pool service.
7. Complete a.-f. by placing an " X in the "YES or "NO" box. If you " X a box marked with an (*), explain your answer below.
NO
YES
a. Did you work on any day claimed for any person or company or were you self-employed? ........................................
b. Were you sick or injured on any day claimed? ............................................................................................................. *O
q
c. Were you ready and willing to work on all days claimed? .............................................................................................
*O
d. Have you quit, resigned, or refused any work since you last claimed benefits? ...........................................................
q
e. Have you been paid a separation allowance by any employer since you last claimed benefits? .................................
*O
f. Are you getting any income such as military reservist pay, vacation or holiday pay, pay for time lost, railroad
guarantee pay, state unemployment benefits, social security benefits, military or other retirement benefits? ..............

*o

d

*a
*a

1

8.

*EXPLANATION:
CERTIFICATION: I certify that I have read Booklet UB-10 and understand it. I know 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. The
information given on this form is true, correct, and complete.
DO NOT SIGN, DATE, OR MAIL THlS CLAIM BEFORE THE LAST DAY OF THlS CLAIM PERIOD
(
1
Signature
Date
Telephone No.

FORM UI-3 (04-04)