UI-1 (03-12) Application for Unemployment Benefits and Employment Ser

CURRENT

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0022

Application for Unemployment Benefits
and Employment Service
Instructions
Before completing this application, read the section Instructions for Completing Application for Unemployment Benefits and Employment Service (Form UI-1) in the UB-10 booklet, which explains information needed to answer questions on this
application. PRINT all answers in ink or use a typewriter. See the UB-10 booklet for the Privacy and Paperwork Reduction Act Notices.

Section A
Instructions

Identifying Information
2. Social Security Number

1. Name (First, Middle Initial, Last)

4. Date of Birth
Month
Day

3. Mailing Address (Include Apartment Number)

City, State, ZIP Code

J Male
J Female

County

6a. Home/Cell/Message Telephone Number (Include Area Code)

Section B
Instructions

5. Sex
Year

6b. Work Telephone Number (Include Area Code)

Employment Information

7a. Last Railroad you worked for
b. Last Railroad Job Title (i.e., Clerk, Trainman, etc.)
c. Location of Last Railroad Job (City and State)
d. Why are you not now working for your last railroad employer? Check one:

J 1. Laid Off/Furloughed/Abolished/Bumped
J 2. Extra Board/Part-Time
J 3. Sick or Injured
Explanation
e. Have you quit or resigned any work
(railroad or other) during the last 3 years?

J 4. Quit or Resigned
J 5. Retired
J 6. Discharged

J 7. Suspended
J 8. Strike/Work Stoppage
J 9. Other, explain below

J Yes - Complete (1) & (2) below

J No - Go to Item 7f.

J Yes - Complete (1) - (4) below

J No - Go to Item 7g.

(1) Date resigned or quit and Employer’s Name
(2) Date resigned or quit and Employer’s Name
f. Are you discharged or suspended?
(1) Date of discharge or suspension period: From

To

(2) Are you seeking reinstatement to your job?

J Yes

J No

(3) Will you claim pay for time lost?

J Yes

J No

(4) Name of Union Official
Address

City, State, ZIP Code
Telephone Number (Include Area Code)

(

)

g. Complete this item ONLY if you are unemployed due to a strike or work stoppage.
Name of your labor union
Refer to the instructions in Booklet UB-10 before completing Item 8.
8a. Date you want your first claim to begin.
b. Date you last worked for a railroad before date in Item 8a.
CONTINUE ON NEXT PAGE

UI-1 (03-12)

9. Are you covered by a job protection plan guaranteeing you a certain amount of work or pay?

J Yes

J No

If “Yes,” enter name of employer providing the guarantee, below.
Employer
10. Have you been paid severance pay or a separation allowance?

J Yes - Complete a. and b., below J No - Go to Item 11

a. Date of separation
b. Name of employer that paid

J Yes - Complete a. and b., below J No - Go to Item 12

11. Have you been self-employed in the past 2 years?
a. Type of self-employment
b. Date you were last self-employed
12. a. Have you been employed by a nonrailroad
employer in the past 2 years?

J Yes - Complete (1)-(5) and b., below J No - Go to Item 13

(1) Employer Name
(2) Employer Address (Street, City, State, ZIP Code)
(3) Date Last Worked

(4) Occupation

(5) Reason Not Working
b. Did you have other nonrailroad employment in the past 2 years?

J Yes

13. Are you an active member of the National Guard or a military reserve unit?

Section C
Instructions

J No
J Yes

J No

School Information

14. a. Are you now attending school?
b. Do you plan to attend school in the next 6 months?

J Yes - Go to Item 15
J Yes

J No - Complete b., below
J No

If “Yes,” enter the month and year you will begin school

Section D
Instructions

Other Benefits

15. Are you receiving social security benefits, military retirement, retainer pay,
or any other unemployment, retirement or survivor benefits
J Yes - Complete a.-c., below
provided by law?
a. Type of benefit(s)

b. Effective date

c. Monthly amount before deductions

Section E
Instructions

J No - Go to Item 16

$

Attach a copy of your most recent award notice.

Direct Deposit Information

16. Benefits are normally paid by Direct Deposit to your bank, savings and loan, credit union, or other financial institution. To
provide the information we need to correctly deposit your payments, attach a voided personal check and go to Item 17, or
call your financial institution for the information you need to complete Items a. through d.
a. Routing Transit Number
c. Account Type: J Checking

b. Account Number

J Savings

d. Name of Financial Institution

Section F
Instructions

Certification and Signature

17. I certify that the information I have provided on this form is true, correct, and complete. I know that I must immediately
report to the Railroad Retirement Board any changes which might affect my entitlement to benefits. I understand that
disqualifications and civil and criminal penalties may be imposed on me for false or fraudulent statements or claims or for
withholding information to get benefits. I understand and agree to the requirements set forth in Booklet UB-10.

SIGNATURE
UI-1 (03-12)

DATE

Mail your signed application immediately to the Railroad Retirement Board using the enclosed envelope.