G-208 (09-04) Public Service Pension Questionnaire

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

FORM APPROVED
OMB NO. 3220-0136

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PUBLIC SERVICE PENSION QUESTIONNAIRE

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SECTION 1 IDENTIFYING INFORMATION
Check the information entered for Items Ithrough 4. If it is not correct, cross out the incorrect information and enter the
correct information above it. Fill in missing information.
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Railroad Employee's Claim Number with Prefix

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2

Railroad Employee's Social Security Number
Railroad Employee's Name
Your Name

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SECTION 2 GENERAL ENTITLEMENT INFORMATION
This section must always be completed if you arelwere employed by the Federal, State, or Local Government in the USA,
its territories, or the Commonwealth of Puerto Rico. A form must be completed for each Public Service Pension you are
receiving.
5 Enter an "X" in the appropriate box:
I am receiving, or will receive, a pension, annuity, or a lump-sum payment in
Yes - Go to Item 6
lieu of an annuity based on my own earnings from Federal, State, or local
public service. Answer "No" if your only government pension payments are or
NO GO to Section 8
will be Social Security, Railroad Retirement, Veteran's Affairs, Worker's
Compensation or Black Luna
" Benefits.
To
From
6 Enter the beginning and ending dates of the period in which you were
Month
Year
Month I Year
employed in a position covered by your Public Service Pension Plan.

a
a _

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SECTION 3 EMPLOYED BY STATE OR LOCAL GOVERNMENT

Complete this Section if you arelwere employed by a State or Local Government. If not, go to Section 4.

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8

Enter an "X" in the appropriate box:
My employer is an instrumentality of two or more states organized as a
corporation to carry on a government function.
Enter the date you last worked in public service employment. If the date is before
July I,2004, go to ltem 9. If the date is after June 30, 2004, go to ltem 10.

a Yes - Go to Section 8
a No - Go to ltem 8

Enter an "X" in the appropriate box:
On my last day of public service employment social security (FICA) taxes
were being deducted from my earnings.
Enter an "X" in the appropriate box:
Were social security (FICA) taxes deducted from your public service
employment for at least 60 months?
Enter an "X" in the appropriate box:
Were social security (FICA) taxes deducted from your public service
employment after March 2, 2004?

a Yes - Go to Section 8
a No - Go to Section 5
a Yes - Go to ltem I 1
a No - Go to Section 6
a Yes - Go to Section 8
a No - Go to Section 6

Month

Year

Day

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SECTION 4 FEDERAL EMPLOYMENT

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Complete this Section if you arelwere a Federal employee.

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Enter an "X" in the appropriate box:
I was hired after 12-31-1983 and receive, or expect to receive, a pension
based in part on my federal service.

m Yes - Go to Section 8

I was hired under CSRS and elected FERS.

m

a No - Go to Item 13
a Yes - G o to ltem 14

No - Go to Section 5

Month

Enter your FERS Election Date.

Day

Year

NOTE: A dated copy of your FERS election is required.

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Form G-208 (09-04) DESTROY PRIOR EDITIONS

If the date in ltem 14 is in 1998, go to ltem 15
If the date in ltem 14 is before 7-1-88, go to Section 8.

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a Yes - Go to Section 8

Enter an " X i n the appropriate box:
I worked under FERS for 60 months after my election.

15

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SECTION 5 ELIGIBILITY IN JULY 1983 OR EARLIER
If you could have qualified for this pension in July 1983 or earlier, complete the following section, otherwise, go t o
Section 6.
NOTE: You must submit a statement from your employer giving the earliest date on which you could have retired.
16

Month

Enter the earliest date you could have qualified for this pension if you had
stopped working (e.g., early retirement or reduction in force).

Year

Day

If the date you entered in ltem 16 is November 1982 or earlier and you are the employee's wife, widow, or divorced
wifelsurviving divorced wife who was married to the employee for 20 or more years, go t o Section 8.
If the date you entered in ltem 16 is November 1982 or earlier and you are the employee's husband, widow(er), or
you were
divorced husbandlsurviving divorced husband who was married to the employee for.20 or more years
receiving at least one-half support from the railroad employee at the time she became entitled to a retirement or disability
annuity or died, go to Section 8. You must submit Form G-134, Statement Regarding Contributions And Support.
If the date you entered in ltem 16 is after November 1982 and before August 1983, n o t o ltem 17.
17 Enter an "X" i n the appropriate box:
I was receiving at least one-half support from the railroad employee at the time
Yes - Go to Note
(s)he became entitled to a retirement or disability annuity or died.
No - Go to Section 6
(If 'Yes," you must submit Form G-134, Statement Regarding Contributions
and SUDDO~~.)

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NOTE: I f the date vou entered in ltem 16 is in December 1982 or in Julv 1983. ao to ltem 18.
Enter an "X" i n the appropriate box:
Yes - Go to Section 8
My eligibility for a pension was delayed until the first full month following the
No - Go to Section 6
month in which all other requirements were met.

a
a

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SECTION 6 PUBLIC SERVICE PENSION INFORMATION
19 Enter the date you began to receive, or expect to receive, your pension. If a future
date is unknown, enter the earliest date you are eligible to receive the pension.

Month
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Enter the name and address of
the agency or organization that
pays or will pay your pension.

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Year

Day
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N~~~
Address
City, State, ZIP Code

1 21 1 Enter the name of your public service pension employer. 1

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22

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Enter your public service pension claim number.

Complete Items 23 through 27 if you are receiving a periodic payment.

a Weekly a Bi-weekly
a Monthly

Enter an "X" i n the appropriate box:
How often do you receive your pension?

1

Enter your current pension rate. Enter the amount after reduction for early
retirement or survivor benefits, but before deductions for health insurance,
$
bonds, or other allotments. Do not include Medicare reimbursement.
Enter an "X" i n the appropriate box:
My pension rate has changed since my railroad retirement annuity beginning date.

a Yes - Go to Item 26
a No - Go to 27
Month

Amount

Show the amount(s) of your pension rate and the date@)
of the change@)from your annuity beginning date. Use
Section 7 if you need more space.

26

$
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27
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If you are receiving a pension from a State or local government, enter the
effective date of your next scheduled increase.
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Form G-208 (09-04)

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Year

Day

$
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Month

Day

Year

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Complete Items 28 and 29 if you received a lump-sum payment.
28

Enter the amount of your lump-sum payment.

29

If the lump-sum payment was in lieu of a
periodic pension, enter the specific time
period the annuity would have been payable.

Is
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From
Day

Month

Year

Month

To
Day

Year

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SECTION 7 REMARKS
30 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.

SECTION 8 CERTIFICATION
31 Enter an "X" in the appropriate box:
I will have a guardian or other representative sign this statement on my behalf.

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a Yes - Go to Note
a No _ Go to Item 32

NOTE: The guardian or other representative must sign this statement in Item 32.
1 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 entitlement to a Public Service Pension based on my own employment may affect the amount of
my railroad retirement annuity. I agree to notify the Railroad Retirement Board if I become entitled to a Public
Service Pension, or if the amount of any pension currently payable to me changes.

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Signature
(First Name, Middle Initial,
Last Name)
Date
Daytime Telephone
Number

Month
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Area Code

Day
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Year
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Telephone Number

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If this certification is signed by mark "X" in ltem 32, two witnesses who know the person signing must sign below,
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giving their full addresses and daytime telephone numbers.
II a. Signature of Witness
Address (Number and Street)
City, State, ZIP Code
Daytime Telephone Number

Area Code

Telephone Number

Area Code

Telephone Number

I I b. Signature of Witness
Address (Number and Street)
City, State, ZIP Code
Daytime Telephone Number
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Form G-208 (09-04)

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Paperwork Reduction and Privacv Act Notice
This notice is given under the Paperwork ReductionAct of 1995 and the Privacy Act of 1974. The Privacy Act requires that
the Railroad Retirement Board (RRB) tell you the following whenever we ask you for information:
1.
2.
3.
4.

The law which allows us to ask for the information;
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;
The reason why the information is requested; and,
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 or not 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 information to the individuals, organizations,
andlor agencies indicated below without your approval:
1.
2.
3.

4.
5.
6.
7.

8.
9.
10.
11.
12.
13.
14.
15.

An attorney, the Office of the President, a Congressional office, a labor union or the Department of State's embassy
or consular offices if they allege to be representing you at your request.
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.
A person who will receive benefits on your behalf if the RRB decided that some medical condition keeps you from
receiving your own benefits; such information may also be released to determine whether such a medical condition
exists and who is suitable to receive such benefits for you.
lnformation (including medical records) may be released to people or organizations who are working for the RRB.
The U.S. Treasury Department or U.S. Postal Service to issue checks and to investigate lost, forged, or stolen
checks.
Your last employer (or its insurance company) to make sure that you can receive any private retirement or insurance
benefits which may be offered by the employer.
The Social Security Administration, Center for Medicare & Medicaid Services, Pension Benefit Guarantee Corporation,
Office 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.
The Internal Revenue Service or state and local taxing authorities for figuring your taxes and for use in audits.
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.
The General Accounting Office for audits and collecting overpayments owed to the RRB or the Social Security
Administration.
The U.S. Department of Labor as required by the Federal Coal Mine and Safety Act.
lnformation can be released, in certain cases, for law enforcement purposes and for court proceedings
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.
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.
Professional Standard Review Organizations and State Licensing Boards when services provided by physicians
or practitioners suggests unethical or unprofessional conduct.

We estimate the application process takes an average of 16 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 OMB number. If you wish, send any comments regarding the accuracy of our estimates or any other aspect of
this form, including suggestions for reducing completion time, to the Chief of lnformation Resources Management,
Railroad Retirement Board, 844 N. Rush Street, Chicago, Illinois 60611-2092.
Form G-208(09-04)

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