Statement Regarding Benefit Claim for Days Worked

RUIA Investigations and Continuing Entitlement

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0025 can be found here:

Documents and Forms

Document Name Document Type
Form UI-48 (01-01) Statement Regarding Benefit Claim for Days Worked Form and Instruction
UI-48 (01-01) Statement Regarding Benefits Claimed for Days Worked Form UI-48 (01-01). pdf.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Statement Regarding Benefit Claim for Days Worked	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 322.4

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	UI-48 (01-01)	Statement Regarding Benefits Claimed for Days Worked	Form UI-48 (01-01). pdf.pdf		No		Paper Only

Line of Business: Litigation and Judicial Activities

Subfunction: Resolution Facilitation

Privacy Act System of Records
Title: RRB 6; Unemployment Insurance Record File	FR Citation: 75 FR 43716

Number of Respondents: 14	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	14	9	5
Annual IC Time Burden (Hours)	3	2	1
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.