UI-1(INTERNET) Application for Unemployment Benefits and Employment Ser

Railroad Retirement Board - Online Unemployment Benefits Application -- More Info

Page 1 of 2

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United States of America - Railroad Retirement Board

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About Us I PrMg Security

Providittg Secrrre Internet Services to the Rrrilrotrtl Cotnrn~ttity

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Unemployment Application

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Welcome to the Railroad ~efrementBoard's Online Unemployment Benefit Application.
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If you filed an application for bnernployment benefits since July 1, you do not need to file another application to obtain a claim.
Just telephone your RRB district office to request a claim form. To obtain the telephone number of the district office serving
I
your area, click here.
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If you want your first unempldyment claim to begin more than two weeks in the future, you must file a paper Form UI-I
Application for UnemploymeQtBenefits.
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Only residents of the United States can use this on-line application. If you live outside the United States, print and complete an
application, and mail it to you'r nearest RRB district office.

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Please read the Booklet UB-40, Unemployment Benefits for Railroad Employees or Booklet LIB-IOs, Beneficios de Desempleo
para Empleados ~erroviarioslbefore starting your application.
You will need the following information in order to complete your application. We suggest you gather it before you start. If for
any reason you do not complbte the unemployment application, your partially completed application will be saved for 30 days.

Information that identifies you:
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. -..
4

Address.
Home and work telephone numbers.
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Your ~ m ~ l o y r n eHistory:
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Railroad Retirement Board - Odline Unemployment Benefits Application -- More Info
Date(s) youllast worked for your last employer and non-railroad employer, if any.
Title of you( last railroad job and non-railroad job, if any.

Direct Deposit Idformation:
I

Your Finan.

SEC C School Info

SEC D Other Benefits

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1. Name (First lnit, Mid Init, ~/lst)
2. Social Security Number

3a. Mailing Address
3b. Address Continued
3c. City
3d. State
3e. ZIP Code
3f. County

Ul-I (03-04)

Form Approved
OM6 NO.3220-0022

This is an official U.S.Government website
Last Revised

- 03/04

SEC E Dlrect Deposit Info

Review This Apptlcatlon

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Railroad Retirement Board - 0$ine Unemployment Benefits Application -- Section A - Page 2

United States of America - Railroad Retirement Board

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About US ( Privacy ( Security

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4. Date of Birth

[~onth
I

5. Sex
6a.
Number (Include Area

i

$1

Iselect
. . . . . . . . . . gender
.................

." F 3

Select from the list to show
the date you were born.

4

'

'

;d

.........
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I

6b. Work Telephone Number I
(Include Area Code)
-.

Ul-I (03-04)
Form Approved
OMB NO.3220-0022

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This is an official U.S.Government website
\.

- Last Revised

03/04

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h t t o s : / / s e c u r e . n b . g o v / ~ ~ ~ ~ ~ e &1Sec
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e t 6b.aspx

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Railroad Retirement Board - Online Unemployment Benefits Application -- Section B - Page 1

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About Us ( Privacy ( Security

United States of Amerlca - Rallroad Retirement Board

,

Providirrg Secirre Internet Ser~iicesto the Ririlroird Comnnurrti&

Application, UI-I
SEC A ldentlfying Info

SEC D Other Beneflts

SEC E Direct Deposit Info

Review Thls Application

I

7a. Last Railroad Employer NLme

]select Employer
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Select the name of the
railroad company for which
:you worked most recently, for
i example, "Norfolk Southern."
If it is not listed, or if you
worked for a rail labor
organization, select 'Other
Employer' to enter the name.

.-.... . . . . . . . - . . . . . . . . . . . . . . .

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7b. Last Railroad Job Title (i.e.,
Clerk, Trainman, etc.)

Select
Occupation
. . . . . . . . . .
....................................

.-.-.......

............................

I

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7c. Location of Last Railroad p o b
City & State
I
7d. Why are you not now working
for your last railroad employqr?
I
Select one:

.

.

.

.............................

i

State
............

-.

.....""

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Ul-I (03-04)
Form Approved
OMB NO. 3220-0022

This is an official U.S.Government website
Last Revised

- '.. -_ 03/04

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.,........

,.;\I

Select Reason

I

.,

.........

Kailroad Retirement Board - O$ine Unemployment Benefits Application -- Section B - Page 2

United States of America - Railroad Retirement Board

Providiltg Secirre lnte

7e. Have you quit or resigned any
work (railroad or other) durin$ the
last 3 years?
I
7e(l). Date res~gnedor quit

7e(l). Employer's Name
7e(2). Date resigned or quit

7e(2). Employer's Name

,

Month

Page 1 of 2

About US I Privacy I Security

ri~icesto the R(tiIrotd Coinnrrtnity

pq-TA

If you have quit or resigned
any railroad or nonrailroad
job within the past 3 years,
select "Yes." You must enter
the
date you resigned or quit,
[
I
)
and the name of your former
employer in Item (I).
If you
quit or resigned from more
than one employer, list the
most recent employer first
and the earlier employer
second.

Ul-1 (03-04)

Fonn Approved
OM6 NO. 3220-0022
This is an official U.S.Government website

- ,- Last Revised
'

- 03/04

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Kailroad Retirement Board Odine Unemployment Benefits Application -- Section B - Page 3
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United States of America - Railroad Retirement Board

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7f. Are you discharged or

j

suspended?

;

Iselect

. . . . . . . . . . . . . .

.................

7f(l). Date of discharge or susdension lhnonth
weriod

. . .

*.. . . . . . . . . . . . . . .

)~ay-3
1-3,
.

u ~ v.

. . .>,..:,....:. . .

7f(2). Are you seeking reinstatepent Ise!ect
to your iob?
,
7f(3). Will you claim pay for timg lost? Iselect
I

Ul-1 (03-04)
Form Approved
OMB NO.3220-0022

This is an official U.S.Government website

-

Last Revised

. 03104

show whether you are
claiming unemployment
benefits because you were
discharged or suspended
from your last railroad job.
If "Yes" be sure to complete
all parts of the question. If
you are suspended, enter
both the beginning and
ending dates of the
susnension oeriod in Item 7f

Railroad Retirement Board - Odine Unemployment Benefits Application -- Section B - Page 4

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About Us I Privacy 1 security

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7f(4). Name of Union Official '

Union official

7f(4). Address

7f(4). City, State, ZIP Code
7f(4). Telephone Number (Include
Area Code)

T I - I

7g. If you are unemployed dup to a strike or work stoppage please enter the name of your labor union.
I
Name

I

--

Ul-1 (03-04)
Form Approved
OMB NO. 3220-0022
This is an official U.S.Governmentwebsite

..

Last Revised
03/04

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Railroad Retirement Board - Odine Unemployment Benefits Application -- Section B - Page 5

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About US 1 Privacy I Security

United States of America - Ra~lroadRetirement Board

Providittg Secure Internet Ser~ticesto the Railrond Commt~tity

SEC A identifying Info

SEC B Employment Info

8a. Date you want your first claim l ~ o n. .t .h
to begin
8b. Date you last worked for g
l~onth
railroad before date in Item 8a.
9. Are you covered by a job
protection plan guaranteeingiyou a
certain amount of work o r paf?
9a. Employer Name
i

SEC E Direct Deposit Info

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Form Approved
OMB No. 3220-0022
This is an official U.S.Government website

*

Last Revised
03/04

Enter the date that you want
your first unemployment
claim to begin. The date you
enter should be the first day
after you last worked for
:either a railroad or
'nonrailroad employer and for
which you were available for
work and did not receive any
pay. For example, if you last
worked May 2, and you

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receiv.e,d..uaeatinn.nav.fnc
Mav.

Ul-1 (03-04)

.- ..

Review This Application

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Railroad Retirement Board - Odine Unemployment Benefits Application -- Section B - Page 6

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United States of America Railroad Retirement Board

Provinilng Secure lnternet Services to ilie R~ilrorondCotnmutiiiy

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About US I Privacv 1 security

An application for unemployment benefits must be filed within 30 days of the first day for which you wish to claim unemployment benefits.
If you tried to file your application earlier but were prevented from doing so by circumstances beyond your control, your application may be
I
considered as filed on time.
An employee's lack of knowledde about the filing requirements is not considered to be be a circumstance beyond his or her control.
Please provide the following inf9rmation in the space below to explain why you are filing late:
What actions did you take to obtain and complete your application for unemployment benefits? Provide the dates you took these actions.
Provide the names and titles of any persons who helped you complete and file the application.

Characters Remaining:

pi-

Question 8a indicated your

r E "

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than 30 days ago. Please
'!
explain why the application : -.
is being filed late.
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Ul-1 (03-04)
Form Approved
OMB NO.3220-0022

This is an official U.S.Government website

..

Last Revised
03/04

Kailroad Retirement Board - Online Unemployment Benefits Application -- Application Incomplete

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Un~tedStates of Amer~ca- Railroad Ret~rementBoard

About
-

Providing Secure Internet Services lo the RRilrond Conlnlunify

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Us Privacy Security
Ul-1 (03-04)

Unemployment Benefits Application, U1-1

Form Approved
OMB NO. 3220-0022

2

1I

Incomplete Sections
1

-

An abdit of your application indicates the following page(s) require your attention:

Questions 10-1I
Questions 12-12a3
Questions 12a4-13

I
Please complete the above pages by clicking on one of the links. All the pages on this list must be reviewed before you can
submit your application.
I

This is an official U.S.Government website

Last Revised
03104

1

Kailroad Retirement Board - Online Unemployment Benefits Application -- Section B - Page 7

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About Us ( Privacy ( Secur-.

United States of America - Railroad Retirement Board

Providiltg Secure Inter~lrtServices to the Rcrilrond Comnuitzity

SEC A ldentlfylng Info

SEC E Direct Deposlt info

10. Have you been paid seva)ance
pay or a separation allowanc'p?
10a. Date of separation
I

]select
......
. . . . . . . . . . . . . . . . . . . . -. . . . . . . . . . . . . .

lob. Name of employer that paid

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8.. . . . .

F

.: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.................................

11. Have you been self-emplqyed in )select
..........
the past 2.years?
!.
1Ia. Type of self-employment I
1

.................

A

-

.....................

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11b. Date you were last ~ e l f - e ~ ~ l ]Month
o. . ~. . e. . d. . . . . . . . . . .T
. .J
.D
ya).- .

p-7-T.

Ul-1 (03-04)
Form Approved
OMB NO. 3220-0022
This is an official U.S.Governmentwebsite

Review This Applicatlon

Choose "Yes" if you have
been paid a severance,
termination, separation
allowance or buy-out.

3

Kailroad Retirement Board - Online Unemployment Benefits Application -- Section B - Page 8

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Providing Secure Internet Services to the R~ilrotrdCoinnwnity

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12a. Have you been employel by a [select
. . .
nonrailroad employer in the past 2
years?
II

12a(l). Employer Name
12a(2). Employer Address

I

I

12a(2).Employer City, State, ZIP
Code
12a(3). Date Last Worked

1

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I.

.

.

. . . . . . . . . . . . . . . . . . . . . . . . . . . .

.

.

.

......

.

.....

. . . . . . . . . . .

...........

-...........

-..........................

: )State

. . . . . . . . . . . . . .

....

-. . . . . . . . .

.

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you are not now working for
that em~lover.for
exampli+,"&it," "laid-off,"
7

Ul-I (03-04)
Form Approved
OMB NO. 3220-0022

This is an official U.S.Government website

Last Revised

.

-- 03/04

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Railroad Retirement Board - Online Unemployment Benefits Application -- Section B - Page 9

Page 1 of 2

About US ( P ~ ~ v ( ~Security
cv

United States of Amer~ca- Railroad Retirement Board

I

Providiizg Secure Internet Services to the Rriilrond Community

1

Unemployment Benefits Application, U1-1

SEC A ldenttfylng Info

SEC D Other Benefits

SECE Dlrect Deposit Info

Review Thls Application

12a(4). Occupation
12a(5). Reason not working
past 2 years.

12b. Did you have any other 1
nonrailroad employment in the past
2 years?
I
13. Are you an active msmbel of
the National Guard or a militqry
,
reserve unit?
I

3-1

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Ul-1 (03-04)
Form Approved
OMB NO. 3220-0022
This is an official U.S.Government website
Last Revised

. .. -- 03/04

Railroad Retirement Board - Online Unemployment Benefits Application -- Section C

Page 1 of 2

About US 1 Privacy 1 Security

Unlted States of America - Railroad Ret~rernentBoard

Providittg Seczrre Ittternrt Services to the Rnilrond Cornnzu~lity

SEC A identifying Info

Unemployment Benefits Application, U1-1

1-1

School Information

SEC C School Info

SEC D Other Benefits

1

1select

3
Select "Yes" if you attend
daytime, evening, or weekend '
classes at a school, college,
university or training program.

I

the next 6 months?
14b(l). If "Yes", enter the monip and
year you will begin school.
I

lskle~i
.
] ~ a . n. t h

.

.

,...

A

".

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Ul-1 (03-04)
Form Approved
OM6 NO. 3220-0022
This is an official U.S.Government website
Last Revised
03/04

Review This Application

j

14a. Are you now attending
school?
1 4 b Do you plan to attend schbol in

.-

SEC E Direct Deposit info

Railroad Retirement Board - Odine Unemployment Benefits Applicatioil -- Section D

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About Us ( Privacy 1 security

United States of America - Railroad Retirement Board

Providiltg Secure Internet Sentices to the Rnilrond Comnzurrity

Other Benefits

:

15. Are y o u receiving social
security benefits, military
'
retirement or retainer pay, or'any
other retirement or survivor j
benefits provided by law?
15a. Type of benefit(s)
,

...................................

Select

. . . . . . . . . . . . . . . . . . . . .

la

.........
. . . . . . . . . .

:-a?

I-..

..................................

...........

;

1

Ul-1 (03-04)
Form Approved
OMB NO. 3220-0022
This is an official U.S.Government website
Last Revised
03/04

5

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15b. Effective date
15c. Monthly amount before
deductions

.
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t
:

Unemployment benefits are
. not payable, or are payable at :;$
reduced amount, if you are
also receiving social security
benefits, military retirement 2$
:pay or retainer pay, or any
;.:
other retirement or survivor :$
...:*
benefits provided by law. If
;!:,
y o u are receiving any other .:;....
i benefits under any law, you :.-:.. .
:must answer this item "Yes" ::.
)and saeoifv the tvoe of benefit d

Railroad Retirement Board - Oli,line Unemployment Benefits Application -- Section E

United States of America - Railroad Retirement Board

Providitzg Secure Internet Serificesto the R~ilrofld
Colnnzurzity

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About Us 1 Privacv 1 Security

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16a. Enter the 9-digit ~ o u t i n ~ ; ~ r a n
Number
sit
for your financial institution.
1:2222222222 ~ ; l 7 7 ~ 7 712w34
Then click 'Validate Bank' to See its' name. If the number is not valid or the
vwrong name displays, check the number you entered and try again, or call your
Routlnp
Checking
financial institution to verify tpe number. If you do not have a bank account or
Transit
Account
Number
Number
receiving your payments by qirect Deposit would cause you a hardship, read
the section Waive Direct Depqsit i n the Help Text and skip to item 16d.
Benefits are normally paid by Direct Deposit to your
bank, savings and loan, credit union or other
Enter Your Routing Transit ~ h m b eHere
r
==>
financial institution. To provide the information we
need to correctly deposit your payments, locate
your bank or financial institution's Routing Transit
Number (RTN) on your personal checks. At the
16b. Enter Account Number
:bottomof your check are three sets of numbers.
16c. Select Account Type
\select
The RTN cnnaists nf the finrtniw-nclrnhcrs in the
16d. Check this box if you do not have a checking or savings account,
!or ifDirect Deposit would caube you a hardship.

1

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Form Approved
OM6 NO. 3220-0022

This is an official U.S.Government website
Last Revised

03/04

I
A

Railroad Retirement Board - Online Unemployment Benefits Application -- Section F

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United States of America Railroad Retirement Board

Providing Secure Irtterrt el Services to tile Railroad Conwzunig

Page 1 of 5

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About US I Privacy Securitv

Application Review
Please review your answeis below. To make corrections, click on the tabs above to return to the section of the
application you want to correct. After making any corrections, click on the "Review" tab at the top of the page to return
to this page. Then completk the certification at the bottom in Section F.

1. Name (First Init, Mid lnit, Last)

R

2. Social Sec~~rity
Number:

XXX-XX-XXXX

3a. Mailing Address

18335 Riegel

Duda

I

3c. City

Homewood

3d. State

IL

3e. ZIP Code

I

60430

3f. County

Cook

4. Date of Birth

0711911945

5. Sex
6a. Home/Cell/Message Telephone
Number (Include Area code)
6b. Work Telephone Numtjer (Include
- Area Code)
7a. Last Railroad Employer Name
'-7b. Last Railroad Job Title j(i.e., Clerk,

Male

ILLINOIS CENTRAL RAILROAD COMPANY
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1Submit.aspx

&lroad Retirement Board - Online Unemployment Benefits Application -- Section F
V V b U W b V b l U p b l

Trainman, etc.)
7c. Location of Last Railroad Job - City & Chicago
IL
,
State
7d. Why are you not now working for your Laid OffIFurloughedlJob abolishedWumped
last railroad employer? Select one:
7e. Have you quit or resighed any work
No
(railroad or other) during tHe last 3 years?
7e(l). Date resigned or quit
7e(l). Employer's Name
7e(2). Date resigned or quit
1

7e(2). Employer's Name

,

7f. Are you discharged or suspended?
7f(l). Date of discharge orisuspension
period
7f(2). Are you seeking reinktatenlent to
your job?
1
7f(3). Will you claim pay fo\ time lost?

No

1

7f(4). Name of Union Official
7f(4). Address

7f(4). City, State, ZIP Codg
7f(4). Telephone Number (Include Area
- Code)
79. If you are unemployed due to a strike
-or work stoppage please epter the name
-of your labor union

No
No

Page 2 of 5

Railroad Retirement Board - Oqine Unemployment Benefits Application -- Section F

Page 3 of 5

8a. Date you want your first claim to begin 02/22/2004
This is a test

Late filing explanation

A

8b. Date you last worked for a railroad
before date in Item 8a.
9. Are you covered by a job protection
plan guaranteeing you a certain amount
of work or pay?

0212 112004

No

9a. Employer Name
10. Have you been paid severance pay or
a separation allowance? ,
10a. Date of separation
lob. Name of employer that paid
11. Have you been self-erhployed in the
past 2 years?
11a. Type of self-employrqent
IIb. Date you were last self-employed
12a. Have you been emplqyed by a
Yes
nonrailroad employer in the past 2 years?
AK Steel
12a(l). Employer Name i
!
7200 West Route 421
12a(2). Err~ployerAddress;
12a(2). Employer City, State, ZIP Code

Rockport

12a(3). Date Last Worked

0711012002

12a(4). Occupatio11

Comp Proc Contr Eng

12a(5). Reason not working
.--12b.Did you have any other nonrailroad

-

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Changed Jobs
No

Kailroad Retirement Board - Online Unemployment Benefits Application -- Section F
er I~pluyrrler IL

11 I LI it: pas1 L

years r

13. Are you an active mer/lber of the
National Guard or a militaw reserve unit?

NO

Yes
14a. Are you now attendin:g school?
14b. Do you plan to attend school in the
next 6 months?
14b(l). If "Yes", enter the month and year
you will begin school.
15. Are you receiving social security
benefits, rlilitary retirement or retainer
No
pay, or any other retirement or survivor
benefits provided by law?
15a. Type of benefit@)

15b. Effective date
15c. Monthly amount before deductions
16a. Enter the 9-digit Routing Transit
Number for your financial ipstitution. Then
click 'Validate Bank' to see its' name. If
the number is not valid or the wrong name
displays, check the number you entered
and try again, or call your qnancial
institution to verify the nutdber. If you do
not have a bank account receiving your
payments by Direct Deposjt would cause
you a hardship, read the section Waive
Direct Deposit in the Help Text and skip ta
item 16d.

01

Name of Financial lnstituti~n
I

. -16b. Enter Account Number

Page 4 of 5

Kallroad Ketirement Board - O$ine Unemployment Benefits Application -- Section F

16c. Select Account Type
16d. Check this box if you:do not have a
checking or savings accodnt, or if Direct
Deposit would cause you g hardship.

F

Page 5 of 5'

Checked
q

Section F

-

Certification

I certify that the information I have provided on this form is true, correct and complete. I know that Imust immediately
report to the Railroad Retirbment Board any changes which might affect my entitlement to benefits. I understand that
disqualifications and civil dnd 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.

Ul-1 (03-04)
Form Approved
OM6 NO. 3220-0022

This is an official U.S.Government website
Last Revised
03/04

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