Download:
pdf |
pdfUnited States of America
Railroad Ret~rementBoard
Form Aooroved
OMB NO 3256-0057
Do not write In th~sbox
Date Interwewed
Field Office Record
of Claimant Interview
l=FTT
Paperwork Reduction ActIPrivacy 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 10-112 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 Chief of Information Resources Management, Railroad Retirement Board, 844 N. Rush Street,
Chicago, Illinois 60611-2092.
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 completirlg ltem 19.
1 Your Name (First, Middle, Last),
2 Your Social Security Number b
t:
0
.+
Street
mO
3 Your Mailing Address
E
+
t:
a, 4 Y o u r T e l e p h o n e N u m b e r
-
(Include A r e a C o d e )
Your Payroll o r
Employee Number
city
State
,
Home
Work
(
ZIP Code
)
b
Prospects for Employment and Work History
6 a. Enter the following information about your most recent employment, regardless o f whether you last
worked for a railroad o r nonrailroad employer, worked part-time, o r w e r e self employed.
a
0
I
5
+
c
Employer Street Address
,I
,
Job Title
b
Department
b
I
Employer N a m e
Street
8
State
City
ZIP Code
I
Supervisor's N a m e
and Telephone Number
Date First Employed
b
Date Last Worked
b
Reason No Longer Working
c
0
.+
ms
,
,
Date o f Expected Recall b
1
1
b. Are you suspended or discharged?
Enter the length o f your suspension,
I
0
YES - G o to ltem 6 b ( l )
0
N O - G o t o ltem 7
,0
Y E S - G o t o l t e m 6b(3)
0
N O - G o t o ltem 7
bI
( I ) if applicable.
b
(2) Are you n o w seeking reinstatement
t o your railroad job?
Form UI-35 (03-07)
u,
1 6 b. (3)
Enter the following information about the union official who is handling your case for reinstatement,
b
Official
'I
Title
'I
'I
Address
7
1
Union Name
'
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 ltem 6. Only list employment held in the last 5 years. Include part-time and
self-em~lovment.Enter more recent em~lovmentfirst. If none. enter "None."
1 Address
Employer
Date started
Occupation
Date ended
Employer
Reason for leaving
Address
Date started
Occupation
Reason for leaving
Date ended
I
I
I
1 Address
Employer
Date started
Date ended
Reason for leaving
8 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 f-egister, go to ltem 9.
If you want your name listed o n the central register, complete ltems a, b, and c below.
If you are ONLY applying t o be listed on the central register and are not claiming unemployment benefits
from the RRB, sign your name and date below. Otherwise, go t o ltem 9.
Signature
Date
a. Enter any significant jobs you have held (railroad and nonrailroad) that are not shown in ltems 6 and 7
From
b.
To
Occupation
Employer name
0 YES
Are you willing to relocate for employment?
0
NO
If "YES," check below as many boxes as apply.
1.
Anywhere in US
2.
5 . 0 Southwest
Form UI-35 (03-07)
NortheasffMid-Atlantic
3.
6. O ~ e s f f ~ o r t h w e s t
Page 2
Southeast
4.
MidwesVGreat Lakes
-c
2; .- .-2
C. Do you have "First Right of Hire" under Federal law? .............................
...............
a
a
YES
NO
If "YES," explain.
Other Payments
I
I
I
I
e
I
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?
.......................................
.
.
b. Wages, salary, or pay for time lost?
C. Income from self-employment, farming, or part-time work? .......................................................... ...........
d.
a
a
a
a
a
YES
YES
YES
Payment for National Guard or military reserve duty? .......................................................................................................................... YES
e. Vacation pay
f. Pay in the form of commodities, services, or privileges?
g. Social security, military retirement, or retainer pay,
YES
YES
a
a
a
YES
or other retirement payments or benefits? ...............................................................................................................
h.
State unemployment or sickness compensation,
or workers' compensation?
a
a
a
a
a
YES
i. Separation allowance, severance pay, buy-out?.................................................................................................................... YES
NO
NO
NO
NO
NO
NO
a
a
a
NO
NO
NO
If you answered all parts "NO," g o t o Itern 10.
If you answered any part "YES," describe the payment.
Placement Information Needed to Help You Find Work
7
In this section: describe your education, skills, credentials, experience, and training. This information will be
I
.w
m
u
3
1
used to match you with
job vacancies and to advise you on how and where to look for work.
10 a. Do you have a high school diploma or GED certificate?
b. Did you graduate from trade or vocational school
YES
a
a
a
YES
a
.............................................................................
Y E
a
a
YES
NO
NO
If "YES," enter the trade or vocation you studied. t
a
W
+
C. Did you attend college?
NO
V)
If "NO," go t o Itern 11.
I
If "YES," enter your major field of study. t
d.
Did you obtain a college diploma? ...................................................................
Page 3
NO
Form UI-35 (03-07)
11 a.
Are you now, or will you be, attending school?
...............................................................................................................................
0 YES 0 NO
If "NO," go to ltem 12.
If "YES," enter the requested information below.
Name of school
b
Location
b
Course of study
Date school begins
Date school ends
Class schedule (days, hours)
b.
..
.
.I
1
I
/
Did you attend school while working in your last job? ......................................................
C. Would you quit school now if offered full-time work? ........
12 a.
b.
3
0 YES 0 NO
0 YES 0 NO
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?
0 YES 0 NO
If "NO," explain why not.
4
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 t o ltem 15.
If "YES," explain the circumstances.
Form UI
i (03-07)
Page 4
0 YES 0 NO
Enter the following information about the kinds of work (railroad and nonrailroad) that you are qualified for and
willing to accept:
a.
Kinds of work
b.
Salary
C.
Distance you are
willina to travel
b
1
b
3
Minimum
b
Per
$
16
b
Preferred
Per
$
Miles
Have you applied for work within the last 30 days? ..................................
. . .
. . . . . . . .
CI YES CI
NO
If "NO," go to ltem 17.
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.
17
Are you registered with any State Employment Service or Job Service Program? ..........
.
YES
CI NO
If"NO," go to ltem 18.
I
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.
I
Page 5
Form UI-35 (03-07)
18 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.
19
I certify that the information I have provided on this form is true, correct, and complete. I have been given a
copy of Booklet LIB-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
b
Enter today's date here b
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:
Railroad Retirement Board
W
Telephone Number:
Interviewed by
b
Remarks
Page 7
Form UI-35 (03-07)
Field Office Record of Claimant lnterview
a
a
1
Initial
Subsequent
a
a Group a Telephone aMail
Individual
UI-35 Date
Rights and requirements (Check items explained to claimant.)
Able and available
Separation allowance
Voluntary quit
Workiearnings restrictions
How to file for SI
Work on claimed
Fraud penalty
Vacancies list
Failure to app'ly, accept, report
Appeal rights
Central register
Registration requirements
Duration of benefits
UB-10 provided
Receipt of other benefits
Compensable days
UI-35c provided
Describe the investigation or additional action required.
Determination:
aEligible aAdverse (Prepare Form UI-27g)
Claimant added to Central Register:
a
Yes
No
Record of Interview Input to RUCS:
0 Yes 0
No
Remarks
Determined by
Date
Reviewed by
Date
Darla Vega
Work-seeking advice (If none, explain why.)
Make diligent efforts to find work.
Register with the State Employment Service. If already registered, visit the service regularly for job information.
Read Booklet UB-12, Guide to Finding the Right Job, and follow the work-seeking advice that is appropriate for you.
Contact and attempt to file employment applications with:
None given, seasonal employee. ID-8F sent.
None given, suspended or discharged seeking reinstatement. ID-8E sent.
If seeking reinstatement, stay in contact with your union representative.
None given, working extra-board or part-time railroad. ID-8G sent.
None given, working nonrailroad.
Other:
Form UI-35 (03-07)
Page 8
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:
Make diligent efforts to find work.
Register with the State Employment Service. If already registered, visit the service regularly for job information.
Read Booklet UB-12, Guide to Finding the Right Job, and follow the work-seeking advice that is appropriate for you.
Contact and attempt to file employment applications with:
Other:
I
Page 9
Form UI-35 (03-07)
| File Type | application/pdf |
| File Modified | 2008-07-09 |
| File Created | 2008-07-09 |