Form UI-63 (12-05) UI-63 (12-05) Application for Benefits Due But Unpaid at Death

Form Approved
OMB NO. 3220-0055

In reply refer to
Deceased Employee:
Social Security Number:

APPLICATION FOR BENEFITS DUE BUT UNPAID AT DEATH
Benefits may be due under the Railroad Unemployment Insurance Act on the account of the
deceased employee named above. These benefits were due the deceased employee but unpaid
at the time of his or her death. In order for us to determine the amount payable and the person@)
entitled to these benefits, please:
If you have any questions concerning the corr~pletionof our forms or the documents you must
submit, please telephone us. Return the application on the next page and any other required
documents within 30 days from the date of this letter or you may lose benefits.
Railroad Retirement Board
Important Notice
We estimate the application on the next page takes an average of 7 minutes to complete, including the time 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
completion time, to Chief of Information Resources Management, Railroad Retirement Board, 844 N Rush Street, Chicago,
IL 60611-2092.

United States of America
Railroad Retirement Board

Form Approved
OMB NO.3220-0055

Application for Benefits Due But Unpaid at Death
Paperwork Reduction Act and Privacy Act Notice
The information furnished on this form is needed for paying benefits under Section 2(g) of the Railroad Unemployment Insurance Act
(RUIA). The Railroad Retirement Board's authority for requesting this information is Section 5(b) of the RLJIA. Although you are not
required to furnish this information, no benefits can be paid unless you do so. Please read the "Important Notice" on the previous page.
1 Name and Social Security Number of Deceased Employee

(Name)
(Social Security Number)
2a Name and Address of Widow(er) (Ifthere is no widow(el;), enter "None" and go to Item 3a)
Name:
Street Address:
CityIStatelZIP Code
b Were the deceased employee and the person named above living together at the same address when the employee

died?

a Yes - Go to Item 5

a No - Answer Items (I), (2), and (3) below.

(1)

Why were they not living together and when did they separate?

(2)

Yes
Was the deceased employee under a court order to contribute to herlhis support?
0 Yes - Explain below
Was the deceased employee contributing to herlhis support?

(3)

a

a No
a No

Explain how often and in what amounts contributions were made.
3 a Name, Address, and Telephone Number of Person or Persons Who Paid the Burial Expenses

Name

Address

Total amount of burial expenses $

Telephone No.

Amount Paid

Amount unpaid, if any $

b Has any person named above received, or will any person receive, reimbursement for all or part of the burial

expenses paid?
4

5

a Yes - Explain below a No

Explanation:
Provide the information requested below about the deceased employee's living relatives in the following order:
Children (if no children survive); then Grandchildren (if no grandchildren survive); then Parents. If none of the
preceding relatives survive, list Brothers and Sisters. (Attach a separate sheet ofpaper ifadditional space is ~zeeded)
Name
Relationship
Address

I understand that malung false or fraudulent statements to the RRB or withholding information from the RRB is a
crime subject to criminal and civil penalties. I certify that the information provided is true, complete, and correct to
the best of my knowledge.
Date
Signature
Relationship to Deceased