Form G- 209 (08-08)

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

FORM APPROVED
OMB No. 3220-0154

EMPLOYEE NON-COVERED SERVICE PENSION QUESTIONNAIRE
A modified benefit formula is used to compute railroad retirement Tier 1 benefits for railroad employees and their spouses who are also entitled
to a pension based on employment after 1956 not covered by the Railroad Retirement Act (RR Act) or the Social Security Act (SS Act).
Please read the important notices on page 4 of this form.
IDENTIFYING
INFORMATION

I

Check the information entered by the RRB in Items 1-2 to be sure it is correct. If it is not correct, cross out the incorrect
information and enter the correct information above it. When the correct information is shown, go to Item 3.
I

A
1 1
1

RAILROAD RETIREMENT
CLAIM NUMBER

2

RAILROAD EMPLOYEE'S NAME

-

ENTITLEMENT
INFORMATION

Enter an 'X" in the appropriate box:
I am receiving or expect to receive a pension or annuity based on any
work after 1956 not covered by the RR Act or the SS Act.

Enter an "X" in the appropriate box:
I have received or expect to receive a lump-sum amount, instead of
periodic payments, which is based on any work after 1956 not covered
by the RR Act or the SS Act and this payment is more than just my
contributions to the pension fund plus interest.
Enter an " X in the appropriate box:
I have thirty or more years of coverage under Section 21 5(a)(l)(C)(ii)
of the SS Act.

Q Yes

b

Go to ltem 5

Q No

b

Go to ltem 4

Q Yes

b

Go to ltem 5

QNo

b

Gotoltem18

Q Yes

b

Go to ltem 18

Q No
b Go to ltem 6
..................................................................................................................................
J............................................................

I I

Note:

I !

II II
6

I

The RRB contact representative i s to use the MARC file to complete this item for the applicant
and initial this item here. I

r

I

Note:

DAY

MONTH

Enter the beginning date of the pension or annuity
described in Item 3 or the date of the lump-sum payment
described in Item 4.

I

l

l
I

l

/
I

I

YEAR

l

l

I

I

l

I f the date you entered in ltem 6 i s before January 1, 1986, go to ltem 18.
Otherwise, go to ltem 7.

Enter the earliest date that you could have become eligible for the
pension, annuity, or lump-sum payment described above. "Eligible"
means that you met all of the age and service requirements for the
pension and could have received it if you had filed for it.

-

Note: I f the date you entered in ltem 7 i s before January 1, 1986, attach a copy of your non-covered
service pension plan and go to ltem 18. Otherwise, go to ltem 8.
NON-COVERED
SERVICE
INFORMATION

Enter the name and address of the
agency or organization for whom you
performed service that was not covered
by the RR Act or the SS Act.

I

Enter an "X" in the appropriate box:
My non-covered service pension or lump-sum payment is based on
employment with a non-profit organization that did not have any SS
Act coverage on 12-31-83 and which became covered under the SS
Act as of 1-1-84 or, my non-covered service pension is based on service as a minister.

Q Yes

b

Go to ltem 18

Q No

b

Go to ltem 10

C

I

I

I

1

FORM G-209 (08-08) DESTROY PRIOR EDITIONS

10 Enter all the periods of employment on which your

NON-COVERED
SERVICE

lNFoRMATloN
(cont.)

YEAR

MONTH

-

pension or lump sum is based (include both
employment covered and not covered by the RR
Act or the SS Act).

YEAR

MONTH

covered by the RR Act or the SS Act that are used
to determine your non-covered service pension or
lump sum.
PAYER
INFORMATION

YEAR

DAY

YEAR

TO

organization that pays or will pay your non-covered
service pension or lump sum.

number.
LUMP-SUM

MONTH

12 Enter the name and address of the agency or

13 Enter your non-covered service pension claim

INFORMATION

YEAR

TO

FROM

11 Enter the periods of employment after 1956 not

MONTH

C

Only answer Items 14-15 if you received a lump sum instead of periodic payments.
Otherwise, go to ltem 16.

14 Enter the amount of your lump-sum payment.

$

(SHOW U.S. DOLLARS ONLY)

-

15 Enter the specific period of

MONTH

YEAR

DAY

b

1

MONTH

time for which the payment
FROM
TO
was made.
.--.
---- -..-....-- --- --- -.- ......- ..-.-- -........-........
Note: In cases involving foreign currency, the RRB contact representative is to enter the foreign
exchange ratio as of the date in ltem 15(a).
PENSION RATE

-

16 Enter the monthly amount of the non-covered
service pension you received for the later of:
a. The first day of the month your railroad retirement
annuity began or will begin; or,
b. The beginning date of your non-covered service
pension indicated in Item 6.

-

$
(SHOW U.S. DOLLARS-..-.-ONLY )
.................................................
.....--..------...--.
Note: In cases involving foreign currency, the RRB contact representative
is to enter the foreign exchange ratio as
of the date described in ltem 16(a) or
ltem 16(b).

17 This item is to be completed by the RRB contact representative when converting foreign currency to U.S.
dollars. The source of the foreign exchange ratio is the Federal Reserve Bank Library.

--

+ 1.
Type of Foreign
Currency

Amount in
Foreign Currency
(XI

Foreign Exchange
Ratio
(x) / U.S. Dollars

Amount in
U.S. Dollars

REMARKS
This section is to be used for the continuation of answers to other items. Be sure to include the item number at the beginning of the
answer you wish to continue. You may also use this section to enter any additional information that you feel may be important to include.

FORM G-209 (08-08) Page 2

CERTIFICATION

a Yes
a

Enter an "X" in the appropriate box:
I will have a guardian or other representative sign this statement
on my behalf.
Note:

No

b

Go to Note and Item 19

b

Gotoltem 19

If answered "YES,"the guardian or other representative of the applicant must sign this questionnaire
in ltem 19.

I understand that civil and criminal penalties may be imposed upon me for false or fraudulent statements, or
for withholding information in order to receive benefits under the Railroad Retirement Act. I affirm that to the
best of my knowledge, the information I have provided on this form is true, complete, and correct.
I understand that, if none of the exceptions listed on this form apply, the Tier 1 component of my annuity will
be reduced because of my entitlement to a non-covered service pension based on employment after 1956
not covered by the Railroad Retirement Act or the Social Security Act. The reduction cannot be greater than
one-half of the amount of the non-covered service pension payable in the first month of entitlement to both
the non-covered service pension and the railroad retirement annuity.
If I have completed ltem 16, 1 agree to notify the RRB if my non-covered service pension stops.

SIGNATURE
(First Name, Middle Initial,
Last Name)

0
pziGq 1.
MONTH

TELEPHONE NUMBER

DAYTIME TELEPHONE NUMBER
(Include Area Code)

20 If this certification is signed b y mark (X") in ltem 19, two witnesses who know the person signing must sign below,
giving their full addresses and daytime telephone numbers.

I

SIGNATURE OF WITNESS

ADDRESS (NUMBER AND STREET, CITY, STATE, AND ZIP CODE)

-

DAYTIME TELEPHONE NUMBER
(INCLUDEAREA CODE)

A

AREA CODE

TELEPHONE NUMBER

-......

SIGNATURE OF WITNESS

ADDRESS (NUMBER AND STREET, CITY, STATE, AND ZIP CODE)

DAYTIME TELEPHONE NUMBER
(INCLUDE AREA CODE)
I

TELEPHONE NUMBER

AREA CODE

- ..-..

..

L

FORM G-209 (08-08) Page 3

PAPERWORK REDUCTION ACT AND PRIVACY ACT NO'I'ICES
This notice is given under the Papenvork Reduction Act of 1995 and the PrivacyAct of 1974. The PrivacyAct requires that the
Railroad Retirement Board (RRB) tell you the following whenever we ask you for information:
1) the law which allows us to ask for the information;
2) whether that law requires you to give us the information and what, if anything, might happen to you if you do
not give it to us;
3) the reason why the information is requested; and
4) the persons, organizations, and agencies to which we may release the information without your permission.
The RRB's authority for requesting this information is Section 7(b) of the Railroad Retirement Act of 1974. Providing us with this
information is voluntary on your part. However, if you fail to provide us with the requested information we may be unable to pay
you any benefits. The RRB needs this information to determine whether you are eligible to receive such benefits and, if so, the
amount you are entitled to receive. If your annuity application is approved and we begin to pay you benefits, information that we
may request from you in the future will be used to determine whether you are entitled to continue to receive such benefits.
Although the information we request is almost never used for any purpose other than the payment of benefits under the Railroad
Retirement Act, the RRB does have the authority to release the following information to the indicated individuals, organizations
andlor agencies without your approval:
1) lnformation may be released to an attorney, the office of the President, a congressional office, a labor union
or to the Department of State's embassy or consular offices if they allege to be representing you at your request.
2) lnformation may be released to other people who are receiving benefits based on the same railroad retirement
account as you are if the information affects their payments from the RRB.
3) lnformation may be released to a person who will receive benefits on your behalf if the RRB decides that
some medical condition keeps you from receiving your own benefits; such information may also be released in
determining whether such a medical condition exists and who is suitable to receive such benefits for you.
4) lnformation (including medical records) may be released to people or organizations who are working for the RRB.
5) lnformation may be released to the U.S. Treasury Department or Postal Service to issue checks and to investigate lost,
forged or stolen checks.
6) lnformation may be released to your last employer (or to its insurance company) to make sure that you can receive any
private retirement or insurance benefits which may be offered by the employer.
7) lnformation may be released to the Social Security Administration, Centers for Medicare & Medicaid Services, Pension
Benefit Guarantee Corporation, Oftice of Personnel Management , Department of Veterans Affairs, or Federal, State,
or local welfare or public aid agencies to determine if you can receive benefits from these organizations and if any
previous benefits were paid incorrectly.
8) lnformation may be released to the Internal Revenue Service or to State and local taxing authorities for figuring your
taxes and for use in audits.
9) Your last address and the name of your last employer may be released to the Department of Health and Human
Services to be used in the Parent Locator Service.
10) lnformation may be released to the General Accounting Office for audits and for collecting overpayments owed to the
RRB or the Social Security Administration.
11) lnformation may be released to the U.S. Department of Labor as required by the Federal Coal Mine and Safety Act.
12) lnfonnation may be released in certain cases for law enforcement purposes and for court proceedings.
13) lnformation about the determination and recovery of an overpayment made to you may be released to any other person
from whom any portion of the overpayment is being recovered.
14) Your name and address may be released to a Member of Congress to inform you about current or proposed legislation
which could affect the railroad retirement system.
15) lnformation may be released to ProfessionalStandards Review Organizationsand State Licensing Boards when services
provided by physicians or practitionerssuggests unethical or unprofessionalconduct.

We estimate that this form takes between 1 and 8 minutes per response 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 OWlB number. If you wish,
send comments regarding the accuracy of our estimate or any other aspect of this form, including suggestions for reducing
the completion time to: Chief of lnformation Resources Management, Railroad Retirement Board, 844 North Rush Street,
Chicago, IL 60611-2092.

FORM G-209(08-08)Page 4