UI-45 (11-16) Claimant's Statement - Voluntary Leaving of Work

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

FORM APPROVED
O.M.B. NO. 3220-0079

CURRENT

CLAIMANT’S STATEMENT
_________________
VOLUNTARY LEAVING OF WORK

Social Security Number

Name

PAPERWORK REDUCTION ACT/PRIVACY ACT NOTICES
The information requested on this form is needed to determine whether unemployment benefits are payable to you for days after
you left work voluntarily. Under the Railroad Unemployment Insurance Act (RUIA), an employee is disqualified from receiving
unemployment benefits beginning with the date he or she leaves work voluntarily. The disqualification does not end until the
employee has sufficient railroad earnings to again qualify for benefits. However, if the employee’s leaving was with good cause, the
disqualification does not prevent payment of benefits unless the employee could receive state unemployment benefits or
unemployment benefits under a law other than the RUIA.
The Railroad Retirement Board’s authority for requesting this information is Section 5(b) of the RUIA. Although you are not required
to provide this information, if you fail to do so, we will not be able to pay you benefits.
We estimate this form takes an average of 15 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 the completion time, to the Associate
Chief Information Officer for Policy and Compliance, Railroad Retirement Board, 844 North Rush St., Chicago Illinois 60611-1275.
PRINT ALL ANSWERS IN INK OR USE A TYPEWRITER.

SECTION 1 – INFORMATION ABOUT THE JOB YOU LEFT
A. Name and Address of Employer

(1) Job Title

(2) Rate of Pay

(3) Date Started Work

(4) Date Last Worked

(5) Immediate Supervisor’s Name/Telephone Number
Telephone Number (
B. Description of Job

)

(

)

C. Reason(s) for Leaving (Please provide a detailed explanation.)

(Continue on Next Page)

UI-45 (11-16)

SECTION 2 – INFORMATION ABOUT YOUR OTHER WORK
Show below all your work outside the railroad industry in the last two years. If you need more space than is
provided, attach a separate sheet of paper. If you had no other employment, write “None” in box A, below, and go to
Section 3.
Dates of Employment
Employer’s
Name of Employer
Location
Reason for Leaving
From
To
(Company or Person)
(City and State)
(Month/Year)
(Month/Year)
A.

B.

C.

SECTION 3 – INFORMATION ABOUT OTHER UNEMPLOYMENT BENEFITS
The following questions are about state unemployment benefits and unemployment benefits under any law other than
the Railroad Unemployment Insurance Act.
Name, Address, and Telephone Number
A. Have you claimed any such benefits since
the date you left work voluntarily? If “Yes,”
give the name, address, and telephone
number of the office at which you claimed
Yes
benefits. If denied these benefits, attach a
No
copy of the notice or decision from the
State unemployment office at which you
applied.
(
)
B. If you have not claimed such benefits, do you have the
qualifying work to receive these benefits?

Yes

No

C. Have you exhausted your rights to such benefits?

Yes

No

SECTION 4 – CERTIFICATION
I understand that civil and criminal penalties may be imposed on me for false or fraudulent statements, or for
withholding information in order to receive benefits. I certify that to the best of my knowledge, the information I have
given is true, complete, and correct.
Signature

Date

Return this form to:

U.S. RAILROAD RETIREMENT BOARD

UI-45 (11-16)