Information Collection

Railroad Unemployment Insurance Act Applications

IC 33857 under ICR 202411-3220-016 · OMB 3220-0039.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form ID-11A (04-17) Railroad Unemployment Insurance Act Applications	Form and Instruction
Form ID-11A (04-17) Requesting Reason for Late Filing of Sickness Benefit Railroad Unemployment Insurance Act Applications	Form and Instruction
Form SI-3 (Internet)(08 Claim for Sickness Benefits Railroad Unemployment Insurance Act Applications	Form and Instruction
Form SI-1A (08-21) Application for Sickness Benefits Railroad Unemployment Insurance Act Applications	Form
Form SI-3 (08-21) Claim for Sickness Benefits Railroad Unemployment Insurance Act Applications	Form
ID-11A (04-17) Requesting Reason for Late Filing of Sickness Benefit Form ID-11A (04-17).pdf	Form and Instruction
ID-11A (04-17) Requesting Reason for Late Filing of Sickness Benefit Form ID-11A (04-17).pdf	Form and Instruction
SI-3 (Internet)(08 Claim for Sickness Benefits Form SI-3 (Internet) (08-21).pdf	Form and Instruction
SI-3 (Internet)(08 Claim for Sickness Benefits Form SI-3 (Internet) (08-21).pdf	Form and Instruction
SI-1A (08-21) Application for Sickness Benefits Form SI-1A (08-21).pdf	Form
SI-1A (08-21) Application for Sickness Benefits Form SI-1A (08-21).pdf	Form
SI-3 (08-21) Claim for Sickness Benefits Form SI-3 (08-21).pdf	Form
SI-3 (08-21) Claim for Sickness Benefits Form SI-3 (08-21).pdf	Form
UB-11 (08-21).pdf UB-11, Sickness Benefits for Railroad Employees	IC Document
UB-11 (08-21).pdf UB-11, Sickness Benefits for Railroad Employees	IC Document
Form SI-10 (05-17) stand alone.pdf SI-10, Statement of Authority to Act for Employee	IC Document
Form SI-10 (05-17) stand alone.pdf SI-10, Statement of Authority to Act for Employee	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Railroad Unemployment Insurance Act Applications

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 335

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	ID-11A (04-17)	No		Paper Only
Form and Instruction	SI-3 (Internet)(08-21)	Yes	Yes	Fillable Fileable Signable
Form	SI-1A (08-21)	Yes	No	Printable Only
Form	SI-3 (08-21)	No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: Unemployment Compensation

Privacy Act System of Records

Title: RRB-21-Railroad Unemployment and Sickness Insurance Benefit System

FR Citation: 79 FR 58874

Number of Respondents: 194,395

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 43 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	194,395	-14,773	209,168
Annual IC Time Burden (Hours)	17,126	-1,606	18,732
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
UB-11, Sickness Benefits for Railroad Employees		01/10/2025
SI-10, Statement of Authority to Act for Employee		01/10/2025

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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