Form UI-9 (06-13) UI-9 (06-13) Statement of Employment and Wages

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0025

CURRENT

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

SOCIAL SECURITY NUMBER

Instructions: If you believe you have both the required earnings and service to qualify for benefits, read the important notices on
the next page, 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, and your employer disagrees with the information on this statement, we will have no
basis on which to adjust our records. 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.
1 Payroll Name (List All Names You Have Used In Railroad
2 Social Security Number (List All Numbers You Have Used)
Employment)

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. 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

Wages Earned
In Month

State

Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec

5 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 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

Form UI-9 (06-13)

Paperwork Reduction Act and Privacy Act Notices
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 10 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 60611-2092.

Form UI-9 (06-13)