Certification Regarding Rights to Unemployment Benefits

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0079 can be found here:

Documents and Forms

Document Name Document Type
Form UI-45 (11-16) Certification Regarding Rights to Unemployment Benefits Form
UI-45 (11-16) Claimant's Statement - Voluntary Leaving of Work Form UI-45 (11-16).pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Certification Regarding Rights to Unemployment Benefits	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 320.5

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	UI-45 (11-16)	Claimant's Statement - Voluntary Leaving of Work	Form UI-45 (11-16).pdf		No		Paper Only

Line of Business: Income Security

Subfunction: Unemployment Compensation

Privacy Act System of Records
Title: RRB-6, Unemployment Insurance Records	FR Citation: 79 FR 58874

Number of Respondents: 200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.