UI-23 Claimant's Statement of Service for Railroad Unemploymen

UNITED
STATES OF AMERICA
RAILROAD
RETIREMENT
BOARD

FORMAPPROVED
OMB NO. 3220-0025

I Statement of Service for Railroad /
Unemployment Insurance
Benefits

SOCIAL
SECURITY
NUMBER
NAME(FIRST,MIDDLE
INITIAL,
LAST)

I

Instructions: If you believe you have additional months of service creditable for unemployment and sickness benefit purposes,
complete and return this form to the Railroad Retirement Board, Post Officb Box 10695, Chicago, Illinois 60610-0695. Read the

1

important notices on page 2 of this form. A month of service is a month in which you worked for a railroad, or otherwise received
pay, vacation pay, holiday pay or pay for time lost from an employer covered by the Railroad Retirement Act. Creditable service also
includes military service during certain periods if before entering military service you worked for a railroad in the same calendar year
or the preceding calendar year.
1 Counting all months of creditable service as explained above, I believe I have a total of 120 or more months of service:
If you answered "YES", complete items I a, I b, 2 , 3 and 4 and return
this form to the Railroad Retirement Board. If you answered "NO,
there is no need to complete this form.

YES

1 In counting
my total months of service I have included:
a. Military Service

1

YES

b. Service after

YES

NO

NO

2 In the blocks below show all employer service beginning with January
. Use a separate block for each employer.
Enter an " X under each month in which you worked or received vacation pay or pay for time lost. If you need more space, use the
reverse side of this form.
Department or
Place of Employment
Name of Railroad or
Occupation
Service
Other Employer
State
City

YEAR

JAN.

FEE.

MARCH

Name of Railroad or
Other Employer

3. Have you retired?

APRIL

MAY

JUNE

JULY

AUG.

Occupation

YES

NO

SEPT.

OCT.

Place of Employment
State
City

NOV.

Department or
Service

If your answer is "YES", give date:

4.1 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.
Date

Signature (Do Not Print)

DEC.

I

Paperwork ReductionIPrivacy Act Notice
The Railroad Retirement Board's authority for requesting this information is Section 5(b) of the Railroad
Unemployment Insurance Act. The information requested on this form is needed to determine if you qualify for
extended or accelerated benefits. You do not have to provide the information requested; but if you fail to
respond, we may not be able to pay you 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.