UI-48 (Proposed) Statement Regarding Benefits Claimed for Days Worked

United States of America
Railroad Retirement Board

PROPOSED

Form Approved
OMB No. 3220-0025

Claimant's Name

STATEMENT REGARDING BENEFITS
CLAIMED FOR DAYS WORKED

SS No.
Place of Interview

, has identified **Choose One** to me as a representative of the Railroad Retirement Board (RRB) and has
informed me that under section 5(b) of the Railroad Unemployment Insurance Act, the RRB has the right to ask me to
complete this form but that I am not required to do so. I have been advised that if I do make a statement, it may be used
against me and that I have the right to consult an attorney or other representative before making a statement. After
having been fully informed regarding my rights, I am furnishing the following information voluntarily. I understand that if I
do not furnish a statement, the RRB will make a determination on my claims based on information obtained from other
sources.
Paperwork Reduction Act Notice
We estimate this form takes an average of 12 minutes to complete, including the time for 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 the Associate Chief Information Officer for
Policy and Compliance, Railroad Retirement Board, 844 North Rush Street, Chicago, IL 60611-1275.
Dates
From
To
1a. During what period(s) did you work for the following employer(s):

Name(s) of Employer(s)

b.

Are you willing to accept the record of your employment as shown to you
by the RRB representative?

YES

NO

c.

Did you report this employment on your claim forms when you filed for
benefits under the Railroad Unemployment Insurance Act?

YES

NO

If 'NO," why not?

2.

Did you claim benefits during the time you worked for the employer(s)
shown in Item 1a?

YES

NO

3a.

Have you worked for anyone else since you started claiming benefits?

YES

NO

YES

NO

If "YES," enter the name of the employer(s) for whom you worked.

b.

Did you report this employment on your claim forms?
If 'NO," why not?

UI-48 (XX-XX)

UNITED STATES RAILROAD RETIREMENT BOARD - 2

Form Approved OMB No. 3220-0025
Name:
SS No.:

4a.

b.

When you started claiming benefits were you provided Booklet UB-10,
Unemployment Benefits for Railroad Employees, or Booklet UB-11,
Sickness Benefits for Railroad Employees?

YES

Did you read and understand it?

YES

NO
If “NO,” go to
Item 5a
NO

If "NO," why not?

5a.

Were you interviewed by a representative of the RRB after you began
claiming benefits?

YES

Did the RRB representative tell you about reporting all work and about
the penalties for making false or fraudulent statements?

YES

NO

6.

Do you understand that you should not claim benefits for days on which
you worked?

YES

NO

7.

DId you know it was a violation of the law to claim benefits for days on
which you worked?

YES

NO

8.

Have you ever claimed benefits under the Railroad Unemployment
Insurance Act before the current benefit year?

YES

NO

b.

NO
If “NO,” go to
Item 6

If "YES," during what periods did you claim benefits?

9.

Additional information furnished by claimant:

10.

CERTIFICATION
I,
certify that the information I have given to the RRB representative is true, complete, and correct. I understand
that criminal and civil penalties may be imposed on me for false or fraudulent statements or claims or for
withholding information in order to receive benefits from the RRB.

(SIGNATURE OF CLAIMANT)

(DATE)

Witnessed by:
(RRB REPRESENTATIVE)

(DATE)

UI-48 (XX-XX)