Form SI-10 (06-09) SI-10 (06-09) Statement of Authority to Act for Employee

United States of America
Railroad Retirement Board

Form approved
OMB No. 3220-0034

Statement Of Authority To Act For Employee

It is not necessary to complete this form for an employee who can sign papers or can
sign by mark and understands transactions relating to his or her sickness benefits.

Instructions
1. Complete Section 1 and have the employee's medical doctor complete Section 2. If you are not related to the employee

by blood or marriage, state your relationship and explain why no relative is acting for the employee. For example, an
employee's union representative might explain: "I am his union chairman. He has no immediate family."
2. Complete this statement by following the instructions in the UB-ll booklet under "Instructions for Completing
Forms, Statement of Authority to Act for Employee (SI-10)." Signing this statement gives you the authority to
sign any claim forms on behalf of the employee. When signing claim forms use your full name, and beneath your
signature, write "On behalf of" and the employee's full name.

3. Return this form with the next application or claim form you file with the RRB.

Section 1

Statement of Individual Acting for Employee

It is my belief that
(Employee's Name)

(SocIal SecurIty Number)

whose address is
(Employee's Address)

is at this time incapable of signing forms in connection with obtaining sickness benefits under the Railroad Unem­
ployment Insurance Act; of transacting the necessary business relative to his or her application and claims for such
benefits; and of applying the proceeds of any sickness benefit payments.
I believe the employee to be incapable because

(Briefly describe employee's condition)

My relationship to the employee is
I affirm that, in the transaction of business relating to the application and claims of this employee, including the use
of any benefit payments, I will act on behalf of and in the best interest of the employee. I will promptly notify the RRB
at such time as this employee's condition changes so that I need no longer act for him or her. I understand that criminal
and civil penalties may be imposed on me for providing false, incomplete, or fraudulent statements; using the benefits
received on something other than the claimant; or for withholding information to cause the payment of benefits. I certify
that, to the best of my knowledge, the information I have provided is true, complete, and correct.
IName (please prmt)

!Phone Number

I~ignature

(

Street Address (please prmt)

State 'ZIP Code Date

IClty

I
Section 2

)

I

Statement of Employee's Doctor

I have examined the employee named above and find that he/she is incapable of signing forms and transacting busi­
ness relative to hislher claims for sickness benefits under the Railroad Unemployment Insurance Act.
Name of voctor (please prmt)
IUftice

~treet

Address (please prmt)

NatlOnal Provider Identifier

51·10 (06~09)

~ignature

iC1ty

of Voctor
~tate

ZIP Code I Date

!

United States of America
Railroad Retirement Board

Fonm Approved
OMB No. 3220-0034

Statement of Authority
to Act for Employee

Employee _ _ _ _ _ _ _ _ _ _ _ _ _ __
Social Security Number'---_ _ _ _ _ _ _ __

This statement is to be completed when applying for sickness benefits under the Railroad
Unemployment Insurance Act (RUIA) on behalf of an employee who is incapable of signing
documents and transacting business in connection with his or her benefit payments. The
Railroad Retirement Board's (RRB) authority for obtaining this information is section 5(b)
of the RUIA. It is not necessary to file this statement for an employee who can sign
papers by mark and understand the transactions. In such a case, the application
should be filled out for the employee, signed by the employee by mark, and the mark witnessed
by two persons who should give their full addresses.
Although you are not required to provide information requested on this form, if you fail to do
so, the RRB cannot grant authorization to you to act on behalf of the employee.
We estimate this form takes an average of 6 minutes to complete, (4 minutes for the applicant
and 2 minutes for the doctor), including the time for reviewing the instructions, obtaining 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 aspects of this form, including suggestions for reducing completion time, to Chief of Infor­
mation Resources Management, Railroad Retirement Board, 844 North Rush Street, Chicago,
Illinois 60611-2092.

Please read the instructions on the next page
concerning the completion and return of this
form to the Railroad Retirement Board.

Form 51-10 (06-09)