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United States of America

Form approved

Railroad Retirement Board

OMB No. 3220-0034

Statement Of Authority To Act For Employee

It is not necessary to complete this form for an employee who can sign papers or can

sign by mark and understands transactions relating to his or her sickness benefits.

Instructions:

Instructions

Complete Section 1 and have the employee's medical doctor complete Section 2. If you are not related to the employ-

ee by blood or marriage, state your relationship and explain why no relative is acting for the employee. For exam-

ple, an employee's union representative might explain: “I am his union chairman. He has no immediate family.”

Complete this statement by following the instructions in the UB-11 booklet under “Instructions for

Completing Forms, Statement of Authority to Act for Employee (SI-10).” Signing this statement gives you the

authority to sign any claim forms on behalf of the employee. When signing claim forms use your full name,

and beneath your signature, write “On behalf of ” and the employee’s full name.

Return this form with the next application or claim form you file with the RRB.

Statement of Individual Acting for Employee

Section 1

It is my belief that

(Employee's Name)

(Social Security Number)

whose address is

(Employee's Address)

is at this time incapable of signing forms in connection with obtaining sickness benefits under the Railroad

Unemployment Insurance Act; of transacting the necessary business relative to his or her application and claims

for such benefits; and of applying the proceeds of any sickness benefit payments.

I believe the employee to be incapable because

(Briefly describe employee's condition)

My relationship to the employee is

I affirm that, in the transaction of business relating to the application and claims of this employee, including the use

of any benefit payments, I will act on behalf of and in the best interest of the employee. I will promptly notify the

RRB at such time as this employee's condition changes so that I need no longer act for him or her. I understand that

criminal and civil penalties may be imposed on me for providing false, incomplete, or fraudulent statements; using

the benefits received on something other than the claimant; or for withholding information to cause the payment of

benefits. I certify that, to the best of my knowledge, the information I have provided is true, complete, and correct.

Name (please print)

Signature

Phone Number

(

)

Street Address (please print)

City

State ZIP Code Date

Section 2

Statement of Employee's Doctor

I have examined the employee named above and find that he/she is incapable of signing forms and transacting

business relative to his/her claims for sickness benefits under the Railroad Unemployment Insurance Act.

Name of Doctor (please print)

Signature of Doctor

Office Street Address (please print)

City

State ZIP Code Date

National Provider Identifier

SI-10 (06-09)

Form Si-10 - Application For Sickness Benefits - Railroad Retirement Board, United States Of America Page 4

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