UI-63 (proposed) Application for Benefits Due But Unpaid at Death

Form Approved
OMB NO.3220-0055

In reply refer to

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(s)
entitled to these benefits, please:
If you have any questions concerning the completion of 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
Enclosure

Form Approved
OMB NO.3220-0055

United States of America
Railroad Retirement Board

Application for Benefits Due But Unpaid at Death

- 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 RUIA. Although you are not required to furnish thisinformation, no benefits can be paid unless you do

PAPERWORK REDUCTION ACT/PRNACY
ACT NOTICES

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SO.

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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.
1 Name and Social Security Number of Deceased Employee

2a Name and Address of Widow(er) (Ifthere is no widow(er), enter "None" and go to Item 3a)

Name:
Street Address:
CityIStatelZIP Code:
b Were the deceased employee and the widow(er) living together at the same address when the employee died?
Yes - Go to Item 5.
No - Answer Items (I), (2), and (3) below.
(1) Why were they not living together and when did they separate?

1

a

(2) Was the deceased employee under a court order to contribute to the widow(er)'s support?
Yes
Yes - Explain below.
(3) Was the deceased employee contributing to the widow(er)'s support?
Explain how often and in what amounts contributions were made.

a

No
No

3a Name, Address, and Telephone Number of Person or Persons Who Paid the Burial Expenses.

Name

Address

Telephone No.

Amount Paid

Amount unpaid, if any: $
Total amount of burial expenses: $
b Has any person named above received, or will they receive, reimbursement for all or part of the burial expenses
paid?
Yes - Provide details below. If additional space is needed, use a separate sheet of paper.
No
Details:
4

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Provide the information requested below about the deceased employee's living relatives in the following order:
Children; ifno children survive then Grandchildren; ifno grandchildren survive then Parents. If none of the
preceding relatives survive, enter Brothers and Sisters. (Attach a separate sheet ofpaper ifadditional space is needed.)
Name
Address
I
Relationship

I

5

I understand that making 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.
Signature
Relationship to Deceased
Date

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