Information Collection

Application and Claim for RUIA Benefits Due at Death

IC 33869 under ICR 200810-3220-003 · OMB 3220-0055.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0055 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form UI-63 (12-05) Application and Claim for RUIA Benefits Due at Death	Form and Instruction
UI-63 (12-05) Application for Benefits Due But Unpaid at Death Form UI-63 (12-05).pdf	Form and Instruction
UI-63 (proposed) Application for Benefits Due But Unpaid at Death Form UI-63 (proposed).pdf	Form and Instruction

IC Title:

Application and Claim for RUIA Benefits Due at Death

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 325.5 20 CFR 355.5

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	UI-63 (12-05)	Application for Benefits Due But Unpaid at Death	Form UI-63 (12-05).pdf		No		Paper Only
Form and Instruction	UI-63 (proposed)	Application for Benefits Due But Unpaid at Death	Form UI-63 (proposed).pdf		No		Paper Only

Line of Business: Income Security

Subfunction: Unemployment Compensation

Privacy Act System of Records

Title: RRB-21; Railroad Unemployment and Sickness Insurance Benefit System

FR Citation: 72 FR 73514

Number of Respondents: 200

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	23	23
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.