Form UI-63 (XX-XX) Application for Benefits Due But Unpaid at Death

Form Approved OMB No. 3220-0055

PROPOSED

United States of America

Railroad Retirement Board

<Office Name>

<Office Address>

<Office City, State, ZIP Code>

WWW.RRB.GOV

Toll-Free Number: 1-877-772-5772

Office Hours: M-T-TH-F 9:00 AM to 3:30 PM

Weds. 9:00 AM to 12:00 PM - Closed Federal Holidays

     

     

     

     

     

     

     

     

     

     

In reply refer to

     

     

APPLICATION FOR BENEFITS DUE BUT UNPAID AT DEATH

Benefits may be due under the Railroad Unemployment Insurance Act on the account of the deceased employee named above. These benefits were due the deceased employee but unpaid at the time of their death. In order for us to determine the amount payable and the person(s) entitled to these benefits, please:

If you have any questions concerning the completion of our forms or the documents you must submit, please telephone us. Return the application on the next page and any other required documents within 30 days from the date of this letter or you may lose benefits.

Railroad Retirement Board

Enclosure

United States of America

Form Approved OMB No. 3220-0055

Railroad Retirement Board

Application for Benefits Due But Unpaid at Death
paperwork reduction act/privacy act notices - The information furnished on this form is needed for paying benefits under Section 2(g) of the Railroad Unemployment Insurance Act (RUIA). The Railroad Retirement Board's authority for requesting this information is Section 5(b) of the RUIA. Although you are not required to furnish this information, no benefits can be paid unless you do so. We estimate this application takes an average of 7 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 completion time, to Railroad Retirement Board, ATTN: Bureau of Information Services/Policy & Compliance, 844 N. Rush St., Chicago, IL 60611-1275.
1 Name and Social Security Number of Deceased Employee ,
2a Name and Address of Widow(er) (If there is no widow(er), enter "None" and go to Item 3a) Name: _____________________________________________________________________________________ Street Address: ______________________________________________________________________________ City/State/ZIP Code: __________________________________________________________________________ b Were the deceased employee and the widow(er) living together at the same address when the employee died?  Yes - Go to Item 5.  No - Answer Items (1), (2), and (3) below. (1) Why were they not living together and when did they separate? ____________________________________ _______________________________________________________________________________________ (2) Was the deceased employee under a court order to contribute to the widow(er)’s support?  Yes  No (3) Was the deceased employee contributing to the widow(er)’s support?  Yes - Explain below.  No Explain how often and in what amounts contributions were made. _________________________________ _______________________________________________________________________________________
3a Name, Address, and Telephone Number of Person or Persons Who Paid the Burial Expenses.
	Name	Address		Telephone No.		Amount Paid
Total amount of burial expenses: $_____________________ Amount unpaid, if any: $_____________________
b Has any person named above received, or will they receive, reimbursement for all or part of the burial expenses paid?  Yes - Provide details below. If additional space is needed, use a separate sheet of paper.  No
Details: ______________________________________________________________________________________________
_____________________________________________________________________________________________________
4 Provide the information requested below about the deceased employee's living relatives in the following order: Children; if no children survive then Grandchildren; if no grandchildren survive then Parents. If none of the preceding relatives survive, enter Brothers and Sisters. (Attach a separate sheet of paper if additional space is needed.)
	Name	Address		Relationship			Telephone No.
5 I understand that making false or fraudulent statements to the RRB or withholding information from the RRB is a crime subject to criminal and civil penalties. I certify that the information provided is true, complete, and correct to the best of my knowledge.
Signature			Relationship to Deceased		Date

UI-63 (01-18)