Information Collection

Employer Service and Compensation Reports

IC 33875 under ICR 202507-3220-002 · OMB 3220-0070.

Documents and Forms

Document Name Document Type
Form UI-41 (08-17) Supplemental Report of Service and Compensation Employer Service and Compensation Reports Form
Form UI-41a (07-19) Supplemental Report of Compensation Employer Service and Compensation Reports Form
Form UI-41 (XX-XX) - Pr Supplemental Report of Service and Compensation Employer Service and Compensation Reports Form
Form UI-41a (XX-XX) - P Supplemental Report of Compensation Employer Service and Compensation Reports Form
UI-41 (08-17) Supplemental Report of Service and Compensation Form UI-41 (08-17) Current.pdf Form
UI-41a (07-19) Supplemental Report of Compensation Form UI-41a (07-19) Current.pdf Form
UI-41 (XX-XX) - Pr Supplemental Report of Service and Compensation Form UI-41 (XX-XX) Proposed.pdf Form
UI-41a (XX-XX) - P Supplemental Report of Compensation Form UI-41A (XX-XX) Proposed.pdf Form
Form UI-23 (08-16).pdf UI-23, Statement of Service for Railroad Unemployment Insurance Benefits IC Document
BA-3 (Internet) (01-12).pdf BA-3 (01-12) IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Employer Service and Compensation Reports	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 302

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form	UI-41 (08-17)	Supplemental Report of Service and Compensation	Form UI-41 (08-17) Current.pdf	No	Printable Only
Form	UI-41a (07-19)	Supplemental Report of Compensation	Form UI-41a (07-19) Current.pdf	No	Printable Only
Form	UI-41 (XX-XX) - Proposed	Supplemental Report of Service and Compensation	Form UI-41 (XX-XX) Proposed.pdf	No	Printable Only
Form	UI-41a (XX-XX) - Proposed	Supplemental Report of Compensation	Form UI-41A (XX-XX) Proposed.pdf	No	Printable 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: 380	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	380	230	150
Annual IC Time Burden (Hours)	51	31	20
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
UI-23, Statement of Service for Railroad Unemployment Insurance Benefits	Form UI-23 (08-16).pdf	08/31/2016
BA-3 (01-12)	BA-3 (Internet) (01-12).pdf	08/31/2016

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

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