Form UI-1e (04-04) UI-1e (04-04) Request for Pay Rate Information

Form. Approved
OMB No. 3220-0097

U.S. Railroad Retirement Board
Office of Programs - Operations
P.O. Box 10695
Chicago, Illinois 60610-0695

In reply refer to
SS No

REQUEST FOR PAY RATE INFORMATION
To help us determine if you may be entitled to a higher daily benefit rate under the Railroad
Unemployment Insurance Act (RUIAI, please complete this form and return it to the address shown
above.
from your last
Your daily benefit rate is based on the daily rate of pay you received in
railroad employer and is your basic pay without overtime or extra allowances. Our authority for
requesting this information is Section 5(bI of the RUlA Although your response t o our request
is voluntary, your daily benefit rate will continue at the minimum rate unless we receive this
information.
SS No.
1. Date last worked in
2. Rate of Pay: Amount

-

.

-:: Month

$

Day
Per

3. Name o f Railroad Employer:

(hour, day, month, etc.)
. .

4. Occupation:

5. Location: City

State

I certify that t o the best of my knowledge, the information I have given is true, complete, and correct
I understand that civil and criminal penalties may be imposed on me for false or fraudulent statements,
or for withholding information to cause payment of benefits.
Signature

Date

Paperwork Reduction Act Notice: W e estimate this form takes an average o f 5 minutes to complete. including time for
reviewing the instructions. getting the needed data, and reviewing the completed form. Federal agencies may not conduct o r
sponsor, and respondents are not required t o 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 aspects of this form, including suggestions
for reducing completion time, to Chief o f Information Management, Railroad Retirement Board, 8 4 4 N. Rush Street Chicago,
11 6 0 6 1 1-2092.

Form UI- l e (04-04)