Proposed UI-35 (xx Field Office Record of Claimant Interview

PROPOSED

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0057

Do not write in this box
Date Interviewed
Month
Day
Year

Field Office Record
of Claimant Interview

Paperwork Reduction Act and Privacy Act Notices
Section 5(b) of the Railroad Unemployment Insurance Act authorizes collection of the information being obtained by this form. The information will be
used to determine whether you meet the statutory eligibility requirements for unemployment benefits and will also be used to provide assistance in
job placement. While you are not required to provide the information, failure to do so may prevent us from paying you benefits.
We estimate this form takes an average of 10-1/2 minutes to complete, including the time 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 completion time, to Associate Chief Information Officer of Policy and Compliance, Railroad Retirement Board, 844
N. Rush Street, Chicago, Illinois 60611-1275.
Instructions
Print all answers in ink as neatly as possible. If you need more space for answers, attach a separate sheet of paper identified with your name and
social security number. If you do not know the answer to a question, print “UNKNOWN” in the answer space. If you need help completing this form,
contact the Railroad Retirement Board office shown on page 6. Complete Items 1 through 19 of this form unless the instructions tell you to skip to
another item. Stop after completing Item 19.

1

Your Name (First, Middle, Last)

2

Your Social Security Number

s

Street

Your Telephone Number
(Include Area Code)
Your Payroll or
Employee Number

Section 2
6 a.

Home

State
Work

(

ZIP Code

)

s

4

City

s

Your Mailing Address

s

3

5

Prospects for Employment and Work History

Enter the following information about your most recent employment, regardless of whether you last
worked for a railroad or nonrailroad employer, worked part-time, or were self employed.
Employer Name

s

Street

Job Title

s

Department

s

Supervisor’s Name
and Telephone Number

s

Date First Employed

s

Date Last Worked

s

Reason No Longer Working

s

Date of Expected Recall

s

City

Are you suspended or discharged?

s

(2)

Enter the length of your suspension,
if applicable.
Are you now seeking reinstatement
to your railroad job?

ZIP Code

o

YES - Go to Item 6b(1)

o

NO - Go to Item 7

o

YES - Go to Item 6b(3)

o

NO - Go to Item 7

s

(1)

State

s

b.

Employer Street Address

s

Information About Your Most Recent Job

Identifying Information
s

Identification

Section 1

Form UI-35 (XX-XX)

Official

s

Title

s

Address

s

Telephone Number
(
)
(Include Area Code)
Enter the following information about all railroad and nonrailroad employment you held at the same time or before
your most recent employment shown in Item 6. Only list employment held in the last 5 years. Include part-time and
self-employment. Enter more recent employment first. If none, enter ”None.”
s

Information About Your Most
Recent Job, Continued

Union Name

s

Information About Prior Jobs

Enter the following information about the union official who is handling your case for reinstatement.

6 b. (3)

7

Employer

Address
Date started

Occupation

Date ended

Employer

Address
Date started

Occupation

Date ended

Employer

Reason for leaving

Address
Date started

Occupation

8

Reason for leaving

Date ended

Reason for leaving

The Railroad Retirement Board (RRB) maintains a central register of former employees who are looking for work
in the railroad industry. The register is furnished to railroad hiring officials upon their request. Notices about jobs
may be sent by the RRB to employees on the register.
If you do not want to be listed on the central register, or your name is already on the register, go to Item 9.
If you want your name listed on the central register, complete Items a, b, and c below.
If you are ONLY applying to be listed on the central register and are not claiming unemployment benefits
from the RR B, sign your name and date below. Otherwise, go to Item 9.

Central Register

Signature
a.

Enter any significant jobs you have held (railroad and nonrailroad) that are not shown in Items 6 and 7.
From

b.

Date

To

Employer name

Occupation

Are you willing to relocate for employment?

o YES

o

NO

If “YES,” check below as many boxes as apply.

1. o Anywhere in US 2. o Northeast/Mid-Atlantic 3. o
5. o Southwest
6. o West/Northwest
Form UI-35 (XX-XX)

Page 2

Southeast

4. o

Midwest/Great Lakes

Central
Register,
Continued

c. Do you have “First Right of Hire” under Federal law?

 YES

 NO

If “YES,” explain.

Section 3

Other Payments

Information About Other Payments

9 Have you received or applied for, or do you expect to receive or apply for, any of the following payments?
a. Job protection or wage guarantee payments?

 YES  NO

b. Wages, salary, or pay for time lost?

 YES  NO

c. Income from self-employment, farming, or part-time work?

 YES  NO

d. Payment for National Guard or military reserve duty?

 YES  NO

e. Vacation pay?

 YES  NO

f. Pay in the form of commodities, services, or privileges?

 YES  NO

g. Social security, military retirement, or retainer pay,
or other retirement payments or benefits?

h. State unemployment or sickness compensation,
or workers’ compensation?

i. Separation allowance, severance pay, buy-out?

 YES  NO
 YES 

NO

 YES 

NO

If you answered all parts “NO,” go to Item 10.
If you answered any part “YES,” describe the payment.

Section 4

Placement Information Needed to Help You Find Work

10 a. Do you have a high school diploma or GED certificate?

 YES  NO

b. Did you graduate from trade or vocational school?

 YES  NO

If “YES,” enter the trade or vocation you studied.

Past Education

In this section, describe your education, skills, credentials, experience, and training. This information will be
used to match you with possible job vacancies and to advise you on how and where to look for work.

 YES  NO

c. Did you attend college?
If “NO,” go to Item 11.

If “YES,” enter your major field of study.

 YES  NO

d. Did you obtain a college diploma?
Page 3

Form UI-35 ( XX-XX)

11 a.

Are you now, or will you be, attending school?

o YES o

NO

Current School Attendance

If “NO,” go to Item 12.
If “YES,” enter the requested information below.

Date school begins

s

Date school ends

s

Class schedule (days, hours)

s

Licenses, Skills, Training
and Experience

s

Ability
to Work

s

Course of study

Did you attend school while working in your last job?

o YES o

NO

c.

Would you quit school now if offered full-time work?

o YES o

NO

b.

Licenses and Certificates—List your licenses and certificates, if any, that may be helpful in obtaining
employment (for example, class “D” drivers license, FCC or real-estate license, or journeyman certification).

Special Skills, Training, and Experience — List your special skills, training, and experience that may be
helpful in obtaining employment (for example, stenography, word processing, operation or repair of mechanical or electronic equipment, TIG welding, knowledge of tax law, computer training).

Are you physically able to work in your regular job?

o YES o

NO

o YES o

NO

If “NO,” explain why not.

14

Personal
Circumstances

s

Location

b.

12 a.

13

Name of school

Are there any personal circumstances which would keep you from accepting work
now, such as child care responsibilities, lack of transportation, or your health?
If “NO,” go to Item 15.
If “YES,” explain the circumstances.

Form UI-35 (XX-XX)

Page 4

Enter the following information about the kinds of work (railroad and nonrailroad) that you are qualified for and
willing to accept:

c.

Distance you are
willing to travel

3

s

Salary

2
Minimum

s

b.

1

s

16

Kinds of work

s

a.

s

Information About the Kinds
of Work You Will Accept

15

$

Preferred
per

$

per

Miles

Have you applied for work within the last 30 days?

o YES o

NO

If “NO,” go to Item 17.

Information About Your Efforts
to Find Work

If “YES,” enter the requested information below about those from whom you attempted to find work.
NOTE: If you have made more than 5 work-seeking attempts, continue this information on a plain sheet of paper.

Employer

City and State

Kind of work

Date
contacted

Results

a.
b.
c.
d.
e.

State Employment Service

17

Are you registered with any State Employment Service or Job Service Program?
Are you registered with the State Employment Service?
If “NO,” go to Item 18.

o YES o NO

If “YES,” complete Items a, b, and c below.

a.

Enter the address and telephone number of the State Employment Service office where you registered for
job placement assistance.

b.

Enter the date you last contacted the State Employment Service about job opportunities.

c.

Enter the result of your contact.

Page 5

Form UI-35 (XX-XX)

Section 5

This section is to be used for the continuation of answers to other items. Be sure to include the item number
at the beginning of the answer you wish to continue. You may also use this section to enter any additional
information that you feel may be imporant to include.

Remarks

18

Remarks

Form UI-35 (XX-XX)

Page 6

Section 6

I certify that the information I have provided on this form is true, correct, and complete. I have been given a
copy of Booklet UB-10 and have been told to read it. I know that I must immediately report to the Railroad
Retirement Board (RRB) any changes which might affect my entitlement to benefits. I understand that civil and
criminal penalties, including a fine and imprisonment may be imposed on me for false or fraudulent statements
or claims or for withholding information to get benefits from the RRB.

Sign your name here

s

Enter today’s date here

s

Your Certification

19

Certification

STOP HERE: Item 19 is the last item for you to complete on this form. Take time now to go back over this form
to make sure you have answered each item accurately and completely. If you are about to be interviewed, give
this form to the RRB representative who will interview you. If you received this form by mail, return it in the
enclosed pre-addressed envelope. If you do not have the envelope, mail the form with sufficient postage to:

%

Telephone Number:

Interviewed by

s

Interviewer’s Signature and Remarks

FOR RRB USE ONLY

Remarks

Page 7

Form UI-35 (XX-XX)

Field Office Record of Claimant Interview
o Initial

o Subsequent

o Individual

o Group

o Telephone

o Mail

UI-35 Date

Rights and requirements (Check items explained to claimant.)

o

Able and available

o

Separation allowance

o

BA-6

o

Voluntary quit

o

Work/earnings restrictions

o

How to file for SI

o

Work on claimed day

o

Fraud penalty

o

Vacancies list

o

Failure to apply, accept, report

o

Appeal rights

o

Central register

o

Registration requirements

o

Duration of benefits

o

UB-10 provided

o

Receipt of other benefits

o

Compensable days

o

UI-35c provided

Record of Interview Input to RUCS:

q Yes q No

Describe the investigation or additional action required.

Determination :

o Eligible

o Adverse (Prepare Form UI-27g)

Claimant added to Central Register: o Yes o No
Remarks

Determined by

Date

Reviewed by

Date

Work-seeking advice (If none, explain why.)

o

Make diligent efforts to find work.

o

Register with the State Employment Service. If already registered, visit the service regularly for job information.

o

Read Booklet UB-12, Guide to Finding the Right Job, and follow the work-seeking advice that is appropriate for you.

o

Contact and attempt to file employment applications with:

o

None given, seasonal employee.

o

None given, suspended or discharged seeking reinstatement.

o

If seeking reinstatement, stay in contact with your union representative.

o

None given, working extra-board or part-time railroad.

o

None given, working nonrailroad.

o

Other:

Form UI-35 (XX-XX)

Page 8

Important reminders

l

l

l

File on time! The RRB must receive your claims within 15 calendar days after the
last day of the claim or the date we mailed the claim to you, whichever is later. If
you file your claim late you may lose benefits.
Fill out claims completely! You must provide all information requested by the
claim form, even if you believe the requested information does not affect your entitlement to benefits. For example, if the RRB or someone else tells you that your
part-time work will not affect your benefits, you must still report such work on your
claims.
Follow-up promptly! If you are expecting a claim form or payment from the RRB
but do not receive it within 20 days, contact the RRB immediately.

Follow the instructions checked below or you may lose benefits:
o

Make diligent efforts to find work.

o

Register with the State Employment Service. If already registered, visit the service regularly for job information.

o

Read Booklet UB-12, Guide to Finding the Right Job, and follow the work-seeking advice that is appropriate for you.

o

Contact and attempt to file employment applications with:

o

Other:

Page 9

Form UI-35 (XX-XX)