UI-3 (Internet) Claim for Unemployment Benefits

Clnrted Slates of P,mer~ca- Ra~lroadRdirernent Board
Provisliug S e c w Ixtewet Serrnices to tke Rnilmad Commwity

About

Claim for Unemployment Benefits -- Form UI-3

Us I Privacy 1 Security
UI-3 (11-04)
Form Approved
OM6 No. 3220-0022

Introduction Page
Welcome to the Railroad Retirement Board's On-line Claim for Unemployment Benefits
Only residents of the United States can use this on-line claim. If you live outside 'the Urlited States, mail your
paper claim to your nearest RRB field office.
Prior to completing your claim form, please carefully read the Booklet UB-10, Unerrlployment Benefits for
Railroad Employees or Booklet UB-I Os, Beneficios de Desempleo para Empleados Ferroviarios.

IMPORTANT: The time limit for filing your claim is 15 days from the last day of the claim period or 15 days
from the date the form was available on the Internet,whichever is later.

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Waiting PeriodiBenefit Payments If this is your first claim in a period of unemployment and you have not
previously satisfied the benefit year waiting period requirement, benefits will be paid to you for your days of
unemployment over 7 in the period. Othemise, benefits are normally payable for the number of days of
unemployment over 4 in each claim period.
Exception: There are special rules for paynient of benefits for days of unemployment due to a strike or work
stoppage.
Allow 15 calendar days from the date you submit your claim on the Internet for a payment to be received. If
you do not receive a payment or other notice within 15 days, contact your local RRB office for information
about the status of your claim.
1421 CHERRY ST
SUITE 660
PHILADELPHIA PA 19102-1493
(215) 6568993

RRB HelpLine -For information about the benefits paid to you or to check on the status of your application or
claim form, call the RRB HelpLine at 1-800-808-0772.

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Direct Deposit If you are not currently receiving payments by Direct Deposit and wish to sign up, please
contact your local RRB office.

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of Recent Benefit Payments:
_ Record
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i ) / t m o u n t l lI ~. Claim
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Date Approved

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'There were no payments issued in the last 90 days
You will need the following information in order to complete your claim form. We suggest you gather it before
you start.
Your Employment History:
Date and location you lastworked for a non-railroad employer, if any.
Train and engine work service during this claim period.
Your Claim Information:
Work status for each day of the claim period.
Dates you did not work during the claim period because of layover, stand-by rule, mileage restriction, or
becaus6 you missed a turn in pool service.

Click here to read these important notices:
Privacv Act Notice
Computer Matchina and Privacy Protection Act Notice
Papemvork Reduction Act Notice
Nondiscrimination on the Basis of Disab~lity
Fraud and Abuse Hot Line
The following claim(s) are available for completion: If you do not wish to frle on the Internet, please file the
paper claims we mailed to you. Do not file both a paper and Internet claim for the same claim period. To begin
your claim for unemployment benefits, click on one of the claim periods listed below.

Cla_im(s] that are currently available for completion:

UAIM(S) AVAILABLE FOR
COMPLE-IION
08/26/2004 through 09/08/2004

Last Revised

1lN4

This is an offlcial U.S.Government nebsite

08/26/2004

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IJriited Ztates of Amer~ca Railroad Retrement B ~ ~ a r d

About Us ] Privacv [ Security

Providzk.g Secavvr I ~ t e w eServices
t
t o the Rnitmnd C o m m i t 2

la. This claim is for unemployment benefits for the 14 consecutive days shown below. To claim benefits,
select the appropriate code ( X,E,P, or 0 ) in the box under each date.
812612004 through 9/8/2004

X - Claimed day of unemployment (Including rest days)
E - Day Employed
P - Vacation or holiday pay
0 - Day not claimed, other reason
l b . Enter the gross amount o f wages andlor other pay (before
$
deductions) that you received or will be paid for days i n this
period. Do not include RRB benefits or payments received
under a supplemental unemployment benefit plan. This item
must be completed if you entered "En or "P" for any day i n Item
I
a.

This is an official U.S.Gwernment webste
Lazt Revised
111174

non-miroad, and self-.
employment. Also,
include any pay you
yould have epr_npd

About Us 1 Privacv Security

United States of A ~ e r o a- Ra~lroadRetirement Board

Late filing explarration
The time limit for filing your claim is 15 days from the last day of the claim period or 15 days from the date the
form
was mailed to you and made available to you online, whichever is later. The 15 days ended on 9/23/2004.
If you tried to file your claim earlier but were prevented from doing so by circumstances beyond your control, your
claim may be considered as filed on time.
An employee's lack of knowledge about the filing requirements is not considered to be a circumstance beyond his or
her control.
Please provide the following information i n the space below for your explanation for late filing:
What actions did you take to obtain and complete your claim for unemployment benefits? Provide the dates these
actions were taken.
Provide the names and titles of any persons who helped you complete and file your claim.
Characters Remaining:

(750

UI-3 (11- 0 4
Form Appraved
OMB N
.; 3220-0022

Th6 13an official U.S.Government website
Last Rev~sed
11104
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United States of America - Railroad Retirement Board
Providing Sscava I~ternafServicas to tks R~iJmatICormrmatni~

2a. Name of last railroad
employer

IBURLINGTON
~
- - NORTHERN AND SANTA FE
- RWY
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l~lectrician
2b. Last railroad job (show
job title, e.g.,
clerk,
trainman,.
etc.)
2c. Reason you are not
working (select the reason)

3. Your claim will be
submitted to the following
address.

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1421 C H E R R Y ST
660
PHILADELPHIA PA 19102-1493

UI-3 (11-04)
F o r m Approved
OMB No. 3220-0022

This is an official U.S.Gouernment website
Last Revised
11104

About Us I Privac!!

I Security

0 . l Select the reason why
you are not now
working for your last
railroad employer. If
you select item 9,
provide an

nnd~nlrmQHOMB

alarm 'KRn,
About US I Privacy ) Securit)

U n k d States of America - Railroad Retiremerrt Baard

4. If your name or address is incorrect, please make appropriate changes.

Name (First lnif Mid lnit,
Last)
Mailing Address
Address Continued .

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ZIP Code
Phone Number

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This item is pre-filled
with your name and
address.lfnecqsary,
show corrections to
@
your name and address.%

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$>File Typeapplication/pdfFile Modified2007-10-30File Created2007-10-30