Form UI-48 (01-01) UI-48 (01-01) Statement Regarding Benefits Claimed for Days Worked

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0025

Claimant's Name

1

STATEMENT REGARDING BENEFITS
CLAIMED FOR DAYS WORKED
Place of Interview
I

, has identified **Choose One**to me as a representative of the Railroad Retirement Board (RRB) and has informed
me that under section 5(b) of the Railroad ~ n e r n ~ l o ~ mlnsurance
ent
Act, the RRB has the right to ask me to complete this
form but that I am not required to do so. I have been advised that if I do make a statement, it may be used against me
and that I have the right to consult an attorney or other representative before making a statement. After having been fully
informed regarding my rights, I am furnishing the following information voluntarily. I understand that if I do not furnish a
statement, the RRB will make a determination on my claims based on information obtained from other sources.
Papetwork Reduction Act Notice
We estimate this form takes an average of 12 minutes to complete, including the time for reviewing the completed form.
Federal agencies may not conduct or sponsor, and respondents are not required to repsond to, a collection of information
unless it displays a valid OlWB number. If you wish, send comments regarding the accuracy of our estimate or any other
aspects of this form, including suggestions for reducing completion time, to the Chief of Information Management,
Railroad Retirement Board, 844 North Rush Street, Chicago, IL 60611-2092.
Dates
From
l a . During what period(s) did you work for the following employers:

b.

Are you willing to accept the record of your employment as shown to you by
the RRB representative?

C.

Did you report this employment on your claim forms when you filed for
benefits under the Railroad Unemployment lnsurance Act?

1

OYES

If 'NO," why not?

1

2.

Did you claim benefits during the time you worked for the employer(s)
shown in Item l a ?

OYES

3a.

Have you worked for anyone else since you started claiming benefits?

OYES

q NO

OYES

q NO

If "YES," list the employers for whom you worked.

1

b.

Did you report this employment on your claim forms?
If 'NO," why not?

I

UNITEDSTATES
RAILROAD RETIREMENT BOARD - 2

Form Approved OMB No. 3220-0025

Name:
4a.

I

b.

SS No.:

When you started claiming benefits were you provided Booklet UB-10 or
Booklet UB-11?

OYES
ONO

Did you read and understand it?

I

If "NO," why not?

Were you interviewed by a representative of the RRB after you began
claiming benefits?

OYES

Did the RRB representative tell you about reporting all work and about the
penalties for making false or fraudulent statements?

OYES

6.

Do you understand that you should not claim benefits for days on which you
worked?

OYES

7.

Dld you know it was a violation of the law to claim benefits for days on
which you worked?

OYES

8.

Have you ever claimed benefits under the Railroad Unemployment
Insurance Act before the current benefit year?

OYES

5a.
b.

ONO
ONO
ONO
ONO

I
I
I
1

If "YES," during what periods did you claim benefits?

9.

Additional information furnished by claimant:

9
, certify that the information I have given to the RRB

1,
(CLAIMANT'S NAME)

representative is true, complete, and correct. I understand that criminal and civil penalties may be imposed on me for
false or fraudulent statements or claims or for withholding information in order to receive benefits from the RRB.

(SIGNATURE OF CLAIMANT)

(DATE)

Witnessed by:
(RRB REPRESENTATIVE)

(DATE)