Form UI-23, Statement of Service for Railroad Unemployment Insurance Benefits

CURRENT

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

Social Security Number

Statement of Service for Railroad
Unemployment Insurance Benefits

Name (First, Middle Initial, Last)

Instructions: If you believe you have additional months of service creditable for unemployment and sickness benefit purposes,
complete and return this form to the Railroad Retirement Board, Post Office Box 10695, Chicago, Illinois 60610-0695. Read the
important notices on page 2 of this form.
Definition of a Month of Service: A month of service is a month in which you worked for a railroad, or otherwise received pay,
vacation pay, holiday pay or pay for time lost from an employer covered by the Railroad Retirement Act. Creditable service also
includes military service during certain periods if before entering military service you worked for a railroad in the same calendar year
or the preceding calendar year.
1 Counting all months of creditable service as explained above, I believe I have a total of 120 or more months of service.
If “YES” - Complete entire form and return to the Railroad Retirement Board.
If “NO” - Do not complete this form.
2 In counting my total months of service I have included:
YES
NO
a. Military Service
YES
NO
b. Service after _________
3 In the blocks below show all employer service beginning with January
. Use a separate block for each employer.
Enter an “X” under each month in which you worked or received vacation pay or pay for time lost. If you need more space, use
the reverse side of this form.
Name of Railroad or
Other Employer

YEAR

Jan.

Feb.

Mar.

Apr.

Name of Railroad or
Other Employer

YEAR

Jan.

Feb.

Jan.

Feb.

May

June

July

Mar.

Apr.

May

June

July

Apr.

May

June

Sept.

Oct.

Aug.

Sept.

Oct.

Place of Employment
City
State

Occupation

Mar.

Aug.

Place of Employment
City
State

Occupation

Name of Railroad or
Other Employer

YEAR

Place of Employment
City
State

Occupation

July

Aug.

Sept.

Oct.

Department or
Service

Nov.

Dec.

Department or
Service

Nov.

Dec.

Department or
Service

Nov.

Dec.

4 Have you retired?
YES - Enter Date: _________________
NO
5 I understand that civil and criminal penalties may be imposed on me for false or fraudulent statements, or for withholding
information to cause payment of benefits by the RRB. I affirm that to the best of my knowledge, the information I have given is
true, complete, and correct.

Signature (Do Not Print): _________________________________________________ Date: __________________

OMB Approval Not Required (<10 Responses Annually)

UI-23 (08-16)

Paperwork Reduction Act and Privacy Act Notices
The Railroad Retirement Board’s authority for requesting this information is Section 5(b) of the Railroad
Unemployment Insurance Act. The information requested on this form is needed to determine if you qualify
for extended or accelerated benefits. You do not have to provide the information requested; but if you fail to
respond, we may not be able to pay you benefits.

OMB Approval Not Required (<10 Responses Annually)

UI-23 (08-16)