Information Collection

Statement Regarding Benefit Claim for Days Worked

IC 179869 under ICR 201704-3220-001 · OMB 3220-0025.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0025 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form UI-48 (08-14) Statement Regarding Benefit Claim for Days Worked	Form and Instruction
UI-48 (08-14) Statement Regarding Benefits Claimed for Days Worked Form UI-48 (08-14).pdf	Form and Instruction

IC Title:

Statement Regarding Benefit Claim for Days Worked

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 322.4

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	UI-48 (08-14)	Statement Regarding Benefits Claimed for Days Worked	Form UI-48 (08-14).pdf		No		Paper Only

Line of Business: Litigation and Judicial Activities

Subfunction: Resolution Facilitation

Privacy Act System of Records

Title: RRB 6; Unemployment Insurance Record File

FR Citation: 79 FR 58874

Number of Respondents: 14

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	14	14
Annual IC Time Burden (Hours)	3	3
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.