Information Collection

Application for Benefits Due but Unpaid at Death

IC 33869 under ICR 202504-3220-017 · OMB 3220-0055.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form UI-63 (01-18) Application for Benefits Due but Unpaid at Death	Form and Instruction
Form UI-63 (01-18) Application for Benefits Due But Unpaid at Death Application for Benefits Due but Unpaid at Death	Form and Instruction
Form Form UI-63 (XX-XX) Application for Benefits Due But Unpaid at Death Application for Benefits Due but Unpaid at Death	Form and Instruction
UI-63 (01-18) Application for Benefits Due But Unpaid at Death Form UI-63 (01-18).pdf	Form and Instruction
UI-63 (01-18) Application for Benefits Due But Unpaid at Death Form UI-63 (01-18).pdf	Form and Instruction
Form UI-63 (XX-XX) Application for Benefits Due But Unpaid at Death Form UI-63 (XX-XX) Proposed.docx	Form and Instruction
Form UI-63 (XX-XX) Application for Benefits Due But Unpaid at Death Form UI-63 (XX-XX) Proposed.docx	Form and Instruction

IC Title:

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 355.5 20 CFR 325.5

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	UI-63 (01-18)				No		Paper Only
Form and Instruction	Form UI-63 (XX-XX) Proposed				No		Paper Only

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: 30

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	30	6	24
Annual IC Time Burden (Hours)	4	1	3
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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

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