UI-35 (03-07) Field Office Record of Claimant Interview

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0057

Do not write in this box
Date Interviewed

Field Office Record
of Claimant Interview

rn

Paperwork Reduction ActlPrivacy Act Notice
Section 5(b) of the Railroad Unemployment InsuranceAct authorizes collection of the information being obtained by this form. The information will be
used to determine whether you meet the statutory eligibility requirements for unemployment benefits and will also be used to provide assistance in
job placement. While you are not required to provide the information, failure to do so may prevent us from paying you benefits.
We estimate this form takes an average of 10-112 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, induding suggestionsfor reducing completion time, to Chief of InformationResources Management, Railroad Retirement Board, 844 N. Rush Street,
Chicago, Illinois 60611-2092.
Instructions
Print all answers in ink as neatly as possible. If you need more space for answers, attach a separate sheet of paper identified with your name and
social security number. If you do not know the answer to a question, print 'UNKNOWN" in the answer space. If you need help completing this form,
contact the Railroad Retirement Board office shown on page 6. Complete Items 1 through 19 of this form unless the instructionstell you to skip to
another item. S t o after
~ com~letina
ltem 19.
.

-

-

@

Identifying Information

.

1 Your Name (First, Middle, Last),
2 Your Social Security Number b

C

0
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m
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O

Street

3 Your Mailing Address

'

4 Your Telephone Number

,

w

C

-a

(Include Area Code)
Your Payroll or
Employee Number

city

State

Home

Work

(

ZIP Code

)

b

Prospects for Employment and Work History
6 a. Enter the following information about your most recent employment, regardless of whether you last
worked for a railroad or nonrailroad employer, worked part-time, or were self employed.
9

Employer Name

b

a

Employer Street Address

,

B

Job Title

b

Department

b

0
7

Street

w

C

0

-

City

State

ZIP Code

U)

I
I

Supervisor's Name
and Telephone Number
Date First Employed

b

I

Date Last worked

t

1

Date of Expected Recall b

I

Reason No Longer Working

1

,
,)

b. Are you suspended or discharged?
(I )

Enter the length of your suspension,
if aoolicable.

Are you now seeking reinstatement

(2) to your railroad job?

1

0

YES - Go to ltem 6b(l)

0

N O - Go to Item 7

,0

YES - G o to Item 6b(3)

0

N O - Go to Item 7

tI
b

Form UI-35 (03-07)

1 6 b. (3)

t;

7

Enter the following information about the union official who is handling your case for reinstatement.
Union Name

b

Official

b

Title

b

Address

b

Telephone Number
[Include Area Code)
(
)
Enter the following information about all railroad and nonrailroad employment you held at the same time or before
your most recent employment shown in ltem 6. Only list employment held in the last 5 years. Include part-time and
self-employment. Enter more recent employment first. If none, enter "None."
Employer

a'

(

I
a
?z

Address

Occupation

I

I

Employer

Address

0
.w

Occupation

C

Employer

Date started

Reason for leaving

Date ended
Address

Date started

Occupation

Reason for leaving

Date ended
I

I

8

Reason for leaving

Date ended

Date started

I

The Railroad Retirement Board (RRB) maintains a central register of former employees who are looking for work
in the railroad industry. The register is furnished to railroad hiring officials upon their request. Notices about jobs
may be sent by the RRB to employees on the register.
If you do not want to be listed on the central register, or your name is already on the register, go to ltem 9.

Ifyou want your name listed on the central register, comblete ltems a, b, and c below.
Ifyou are ONLY applying to be listed on the central register and are not claiming unemployment benefits
from the RRB, sign your name and date below. Othewise, go to ltem 9.

Signature
a.

Enter any significant jobs you have held (railroad and nonrailroad) that are not shown in ltems 6 and 7.
From

b.

Date

To

Occupation

Employer name

--

Are you willing to relocate for employment?

-

If YES," check below as many boxes as apply.

1.

Anywhere in US

2.

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5 . 0 Southwest
Form UI-35 (03-07)

NortheasVMid-Atlantic

6.

rn

3.

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~es~~orthwest
Page 2

Southeast

0YES
4.

rn

a

NO '

MidwesVGreat Lakes

3
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.v, .E

C. Do you have "First Right of Hire" under Federal law?

D YES

-

0

NO

If "YES," explain.

Other Payments

19
I a.

Have you received or applied for, or do you expect to receive or apply for, any of the following payments?

I

I

Job protection or wage guarantee payments?

D YES D
0 YES Q

....

b. Wages, salary, or pay for time lost?

..-..-

C. Income from self-employment, farming, or part-time work?

-

--

d. Payment for National Guard or military'reserve duty?
e. Vacation pay?
f. Pay in the form of commodities, services, or privileges?
g. Social security, military retirement, or retainer pay,
or other retirement payments or benefits?

h.

.

State unemployment or sickness compensation,
or workers' compensation?

NO
NO

D YES
D YES 0
D YES 0
YES D

NO
NO

D YES 0

NO

NO
NO

D YES 0
D YES D

.
.

i. Separation allowance, severance pay, buy-out?

NO
NO

If you answered all parts "NO," go to ltem 10.

If you answered any part "YES," describe the payment.

Placement Information Needed to Help You Find Work
In this section, describe your education, skills, credentials, experience, and training. This information will be
used to match you with possible job vacancies and to advise you on how and where to look for work.

10 a. Do you have a high school diploma or GED certificate?-.-.---c.

s

w"
C
.
V)

.

-

Q YES

D YES

b. Did you graduate from trade o r vocational school?

0
0

NO
NO

If "YES," enter the trade or vocation you studied. b
C. Did you attend c o l l e g e ?

Cj YES

NO

D YES D

NO

If "NO," go to ltem 11.

If "YES," enter your major field of study. b

d. Did you obtain a college diploma?

2-

Page 3

.---

Form UI-35 (0347)

I

11 a.

Are you now, or will you be, attending school? ---

--------

QYES

m NO

If "NO," go t o ltem 12.
If YES," enter the requested information below.
Name of school

b

Location

b

Course of study

b

Date school begins

b

Date school ends

b

Class schedule (days, hours)

I
I

b.

b.

.-cz
5%

-

-----

m YES m NO
a YES m NO

Licenses and Certificates--List your licenses and certificates, if any, that may be helpful in obtaining
employment (for example, class 'D" drivers license, FCC or real-estate license, or journeyman certification).

Special Skills, Training, and Experience- List your special skills, training, and experience that may be
helpful in obtaining employment (for example, stenography, word processing, operation or repair of mechanical or electronic equipment, TIG welding, knowledge of tax law, computer training).

Are you physically able to work in 'your regular job? -------

--------

5 YES

m NO

m YES

NO

o

14

cn

-a 8c

Are there any personal circumstances which would keep you from accepting work
now, such as child care responsibilities, lack of transportation, or your h e a l t h ? . - - -

~f" ~ 0go, t~
o Item
~ 15.

2

L

----

If 'NO," exblain why not.

0

a

Did you attend school while working in your last job? -

C. Would you quit school now if offered full-time work?

12 a.

13

,

If 'YES," explain the circumstances.

€

0 ,

2

G

I

Form 111-35 (03-07)

Page 4

15

U1

u

5

Enter the following information about the kinds of work (railroad and nonrailroad) that you are qualified for and
willing to accept:

.w

n

ng

a.

alo

55

zz

Kinds of work

2z
5

.-O 3
iii

b. Salary

0

e-E€ '3;i

C.

16

I1

Distance you are
willing to travel

1

b

,3
,
,

Minimum

Preferred
~ e r

$

per

$

Miles

0 YES 0 NO

Have you applied for work within the last 30 days? If "NO." go to ltem 17.

If "YES," enter the requested information below about those from whom you attempted to find work.
NOTE: If you have made more than 5 work-seeking attempts, continue this information on a plain sheet of paper.

17

(

Are you registered with any State Employment Service or Job Service Program? .

-

YES

0 NO

If "NO." go to ltem 18.
If 'YES," complete Items a, b, and c below.

a.

Enter the address and telephone number of the State Employment Service office where you registered for
job placement assistance.

b.

Enter the date you last contacted the State Employment Service about job opportunities.

C.

Enter the result of your contact.

I

Page 5

Form IJI-35 (03-07)

1 18

This section is to be used for the continuation of answers to other items. Be sure to include the item number
at the beginning of the answer you wish to continue. You may also use this section to enter any additional
information that you feel may be imporant to include.

-

Certification
I

19

1 certify that the information I have provided on this form is true, correct, and complete. I have been given a
copy of Booklet UB-10 and have been told to read it. I know that I must immediately report to the Railroad
Retirement Board (RRB) any changes which might affect my entitlement to benefits. I understandthat civil and
criminal penalties, including a fine and imprisonment may be imposed on me for false or fraudulent statements
or claims or for withholding information to get benefits from the RRB.

Sign your name here

b

Enter today's date here b
STOP HERE: Item 19 is the last item for you to complete on this form. Take time now to go back over this form
to make sure you have answered each item accurately and completely. If you are about to be interviewed, give
this form to the RRB representative who will interview you. If you received this form by mail, return it in the
enclosed pre-addressed envelope. If you do not have the envelope, mail the form with sufficient postage to:

Telephone Number:

Interviewed by

b

Remarks

Page 7

Form 111-35 (03-07)

Field Office Record of Claimant Interview

a

a Initial

Subsequent

a Individual

a Group a Telephone

0 Mail

UI-35 Date

Rights and requirements (Check items explained to claimant.)
Able and available

Separation allowance

BA-6

voluntary quit

Worklearnings restrictions

HOW

Work on claimed day

Fraud penalty

Vacancies list

Failure to apply, accept, report

Appeal rights

Central register

Registration requirements

Duration of benefits

UB-10 provided

Receipt of other benefits

Cornpensable days

UI-35c provided

to file for SI

Describe the investigation or additional action required.

Determination:

aEligible aAdverse (Prepare Form UI-27g)

Claimant added t o Central Register:

0 Yes 0 No

Record o f Interview Input to RUCS:

Yes

No

I

Remarks

Determined by

Date

Reviewed by

Date

Work-seeking advice (If none, explain why.)
Make diligent efforts to find work.
Register with the State Employment Service. If already registered, visit the service regularly for job information.
Read Booklet UB-12, Guide to Finding the Right Job, and follow the work-seeking advice that is appropriate for you.
Contact and attempt to file employment applications with:
None given, seasonal employee. ID-8F sent.
None given, suspended or discharged seeking reinstatement. ID-8E sent.
.If seeking reinstatement, stay in contact with your union representative.
None given, working extra-board or part-time railroad. ID-8G sent.
None given, working nonrailroad.
Other:

Form UI-35 (03-07)

Page 8

File on time! The RRB must receive your claims within 15 calendar days after the
last day of the claim or the date we mailed the claim to you, whichever is later. If
you file your claim late you may lose benefits.
Fill out claims completely! You must provide all information requested by the
claim form, even if you believe the requested information does not affect your entitlement to benefits. For example, if the RRB or someone else tells you that your
part-time work will not affect your benefits, you must still report such work on your
claims.
Follow-up promptly! If you are expecting a claim form or payment from the RRB
but do not receive it within 20 days, contact the RRB immediately.

F o l l o w t h e instructions checked b e l o w or y o u m a y lose benefits:
Make diligent efforts to find work.
Register with the State Employment Service. If already registered, visit the service regularly for job information.
Read Booklet UB-12, Guide to Finding the Right Job, andfollow the work-seeking advice that is appropriate for you.
Contact and attempt to file employment applications with:

Page 9

Form U1-35 (03-07)