UI-41a (01-08) Supplemental Report of Compensation

Form Approved
OMB No. 3220-0070

U.S. Railroad Retirement Board
Office of Programs - Operations
P.O. Box 10695
Chicago, IHinois 60610-0695

01-13-2010

In Reply Refer To
ER No

SUPPLEMENTAL REPORT OF COMPENSATION
A report of compensation for calendar year 2008 is needed to determine the amount of benefits
payable under the Railroad Unemployment Insurance Act (RUIA) to the employee identified below.
Once you have completed the report, plepse return it to: Railroad RetiTement Board. Office of
Programs-Operations, P.O. Box 10695, Chicago IL 60610-0695. Our authority for requesting this
report is section 5(b) of the RUIA Failure to report or the making of a false or fraudulent report
can result in criminal prosecution or civil penalties, or both.
Paperwork Reduction Act Notice:We estimate this form takes an average of 8 minutes per response to complete. including
the time needed 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 the completion time. to Chief of Information Resources Management. Railroad Retirement
Board. 844 N. Rush Street. Chicago, IL 60611-2092.

Employee
SS No.

Address
Payroll No.
ICC Code
ER No.

Report For 2008
Enter the amount of compensation earned eac~
month, up to the monthly maximum of $1,653·

JAN

FEB

MAR _ _ __

APR

MAY _ _ __

JUN
JUL
AUG ____
SEP

OCT

NOV _ _ __

DEC
TOTAL _ _ __
Certification: The information contained in this report is true and correct to the best of my knowledge.
Signature: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _--,-_ _
Date: - - - ­ _ __
. Title:
Railroad:
Form UI-41A (01-08)