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Field Office Record
of Claimant Interview
United States of America
Railroad Retirement Board
Form Approved
OMB No. 3220-0057
Do not write in this box
Date Interviewed
Month
Day
Year
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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 completing Item 19.
1
Your Name (First, Middle, Last)
2
Your Social Security Number
s
Street
Your Mailing Address
s
4
Your Telephone Number
(Include Area Code)
Your Payroll or
Employee Number
s
Section 2
6 a.
State
City
Home
Work
(
ZIP Code
)
s
3
5
Prospects for Employment and Work History
Enter the following information about your most recent employment, regardless of whether you last
worked for a railroad or nonrailroad employer, worked part-time, or were self employed.
Employer Name
s
Street
Job Title
s
Department
s
Supervisor’s Name
and Telephone Number
s
Date First Employed
s
Date Last Worked
s
Reason No Longer Working
s
Date of Expected Recall
s
City
Are you suspended or discharged?
s
(2)
Enter the length of your suspension,
if applicable.
Are you now seeking reinstatement
to your railroad job?
ZIP Code
o
YES - Go to Item 6b(1)
o
NO - Go to Item 7
o
YES - Go to Item 6b(3)
o
NO - Go to Item 7
s
(1)
State
s
b.
Employer Street Address
s
Information About Your Most Recent Job
Identifying Information
s
Identification
Section 1
Form UI-35 (08-23) Exhaust prior editions
Official
s
Title
s
Address
s
s
Information About Prior Jobs
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 Item 6. Only list employment held in the last 5 years. Include part-time and
self-employment. Enter more recent employment first. If none, enter ”None.”
7
Employer
Address
Date started
Occupation
Date ended
Employer
Date started
Date ended
Employer
Reason for leaving
Address
Date started
Occupation
8
Reason for leaving
Address
Occupation
Section 3
Informatiom About Other Payments
Enter the name, address, title, and telephone number of the union official who is handling your case
for reinstatement.
s
Information About Your Most
Recent Job Continued
(3)
Date ended
Reason for leaving
Other Payments
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?
o
YES
o
NO
b.
Wages, salary, or pay for time lost?
o
YES
o
NO
c.
Income from self-employment, farming, or part-time work?
o
YES
o
NO
d.
Payment for National Guard or military reserve duty?
o
YES
o
NO
e.
Vacation pay?
o
YES
o
NO
f.
Pay in the form of commodities, services, or privileges?
o
YES
o
NO
g.
Social security, military retirement, or retainer pay,
or other retirement payments or benefits?
o
YES
o
NO
State unemployment or sickness compensation,
or workers’ compensation?
o
YES
o
NO
Separation allowance, severance pay, buy-out?
o
YES
o
NO
h.
i.
If you answered all parts “NO,” Go to Item 10.
If you answered any part “YES,” describe the payment.
Form UI-35 (08-23)
Page 2
Information
About Other
Payments
Section 4
Placement Information Needed to Help You Find Work
Past Education
In this section, describe your education, skills, credentials, experience, and training. This information will be
used to match you with possible job vacancies and to advise you on how and where to look for work.
9 a.
b.
YES
o
NO
Did you graduate from trade or vocational school?
o
YES
o
NO
c.
o
YES
o
NO
YES
o
NO
Did you attend college?
If “NO,” Go to Item 11.
d.
If “YES,” what was your major field of study?
e.
Did you obtain a college diploma?
o
Are you now, or will you be, attending school?
o YES o
NO
If “NO,” Go to Item 12.
b.
If “YES,” enter the requested information below.
Name of school
s
Location
s
Course of study
s
Date school begins
s
Date school ends
s
Class schedule (days, hours)
s
Current School Attendance
o
If “YES,” enter the trade or vocation you studied.
10 a.
Licenses, Skills,
Training and
Experience
Do you have a high school diploma or GED certificate?
c.
Did you attend school while working in your last job?
o YES o
NO
d.
Would you quit school now if offered full-time work?
o YES o
NO
11 a.
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).
Page 3
Form UI-35 (08-23)
Licenses, Skills,Training
and Experience, Cont.
b.
Ability
to Work
12
o YES o
NO
Personal
Circumstances
Are there any personal circumstances which would keep you from accepting work
now, such as child care responsibilities, lack of transportation, or your health?
o YES o
NO
If “NO,” Go to Item 15.
If you answered “YES,” explain the circumstances.
14
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
1
s
2
s
3
b.
s
c.
s
15
s
Information About the Kinds
of Work You Will Accept
Are you physically able to work in your regular job?
If “NO,” explain why not.
13
Information About Your
Efforts to Find Work
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).
Minimum
$
Preferred
per
$
per
Miles
o YES
Have you applied for work within the last 30 days?
o
NO
If “NO,” Go to Item 17.
If you answered “YES,” give the following information about your attempts to find work:
If you have made more than 5 work-seeking attempts, continue this information on a plain sheet of paper.
Employer
City and State
a.
b.
Form UI-35 (08-23)
Page 4
Kind of work
Date
contacted
Results
Efforts to Find Work
Information About Your
c.
d.
e.
State Employment Service
16
Are Are
you you
registered
with with
any the
State
Employment
Service
or Job Service Program?
registered
State
Employment
Service?
o YES o NO
If “NO,” Go to Item 18.
If “YES,” complete Items a, b, and c:
a.
Give 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.
Section 5
This section is to be used for the continuation of answers to the other items. Be sure to include the item
number at the beginning of the answer you wish to continnue. You may also use this section to enter any
additional information that you feel may be important to include.
s
Your Certification
17
Remarks
s
%
Telephone Number
Page 5
Form UI-35 (08-23)
Section 6
Certification
I certify that the information I have provided on this form is true, correct, and complete. I have been given a
copy of Booklet UB-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
C
0
:.;:;
cu
u
�
s
Your Certification
18
►
Enter today's date here ► ______ _________________
s
t
uL.
STOP HERE: Item 19 is the last item for you to complete on this form. Take time now to go back over this form
Q)
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:
:::J
0
Railroad Retirement Board
Office of Programs/Policy & Systems
844 North Rush Street
Chicago, IL 60611-1275
Telephon Number: 1-877-772-5772
:::J
Interviewer’s Signature and Remarks
FOR RRB USE ONLY
Form UI-35 (08-23)
Interviewed by
► Michelle.Andrey
Remarks
Page 6
FOR RRB USE ONLY
Field Office Record of Claimant Interview
o Initial
o Subsequent
o Individual
o Group
o Telephone
UI-35 Date
o Mail
Rights and requirements (Check items explained to claimant.)
o
Able and available
o
Separation allowance
o
BA-6
o
Voluntary quit
o
Work/earnings restrictions
o
How to file for SI
o
Work on claimed day
o
Fraud penalty
o
Vacancies list
o
Failure to apply, accept, report
o
Appeal rights
o
Central register
o
Registration requirements
o
Duration of benefits
o
UB-10 provided
o
Receipt of other benefits
o
Compensable days
o
UI-35c provided
Describe the investigation or additional action required.
Determination:
o Eligible
o Adverse (Prepare Form UI-27g)
Record of Interview Input to RUCS:
o Yes
o No
Remarks
Determined by
Reviewed by
Date
Date
Michelle Andrey
Work-seeking advice (If none, explain why.)
o
Make diligent efforts to find work.
o
Register with the State Employment Service. If already registered, visit the service regularly for job information.
o
Read Booklet UB-12, Guide to Finding the Right Job, and follow the work-seeking advice that is appropriate for you.
o
Contact and attempt to file employment applications with:
o
None given, seasonal employee.
o
None given, suspended or discharged seeking reinstatement.
o
If seeking reinstatement, stay in contact with your union representative.
o
None given, working extra-board or part-time railroad.
o
None given, working nonrailroad.
o
Other:
o
ID-8F sent.
Page 7
o
o
ID-8E sent.
ID-8G sent.
Form UI-35 (08-23)
Important reminders
l
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.
l
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.
l
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:
o
Make diligent efforts to find work.
o
Register with the State Employment Service. If already registered, visit the service regularly for job information.
o
Read Booklet UB-12, Guide to Finding the Right Job, and follow the work-seeking advice that is appropriate for you.
o
Contact and attempt to file employment applications with:
o
Other:
Form UI-35 (08-23)
Page 8
| File Type | application/pdf |
| File Title | UI-35 09-05 DRAFT.qxp |
| Author | osikagl |
| File Modified | 2023-08-14 |
| File Created | 2007-02-14 |