Form UI-9 Applicant's Statement of Employment and Wages

UNITED
STATES
OF AMERICA
RAILROAD
RETIREMENT
BOARD

FORMAPPROVED
OMB No. 3220-0025

Statement of Employment and Wages
Calendar Year
NAME(FIRST,MIDDLE
INITIAL,
LAST)

NUMBER
SOCIAL
SECURITY

Instructions: If you believe you have both the required earnings and service to qualify for benefits, complete Items 1-5, and
promptly return this form to the Railroad Retirement Board, Post Office Box 10695, Chicago, Illinois 60610-0695. Remember to
attach copies of your pay stubs for the year. If you do not submit copies of your pay stubs or other substantiating evidence, we
will have no basis on which to adjust our records of your service and compensation if your employer does not agree with your
statement. The filing of this form is an irrevocable request to have the record of your base year earnings changed to match the
information you provide on this form, if the change will qualify you for benefits.
1 Payroll Name (List All Names You Have Used In Railroad
1 2 Social Security Number (List All Numbers You Have Ever
Employment)
Used)

3a Date of Birth

3b Sex

Male
3c Father's Name (First, Middle Initial, Last)

Female

3d Mother's Name at Birth (First, Middle, Last)

' 4 Complete the items below for all railroad wages from January 1 to December 31 for the year shown above.
I

If you need more

space use the reverse side of this form.
Name of Railroad or
Other Employer

Occupation

Name of Foreman or
Supervisor

Place of Employment
City or Town

I

Wages Earned
In Month

State

Feb
Mar
APr
May
June
July
Aug
Sept
Oct

5 1 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 by the RRB. I affirm that to the best of my knowledge, the
information I have given is true, complete, and correct.

Signature (Do Not Print)

Date
Please Read The Important Notices On The Next Page

Paperwork Reduction/Privacy Act Notice
The Railroad Retirement Board's authority for requesting this information is Section 5(b) of the Railroad
Unemployment Insurance Act. This information will be used to verify your years of service, counting
both railroad service and military service. You do not have to provide this information; but if you fail to
respond, you may lose some benefits.
We estimate this form takes an average of 5 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 Chief of Information
Resources Management, Railroad Retirement Board, 844 Rush Street, Chicago, Illinois 6061 1-2092.

Form UI-9 (1 1-00)