G-237 Statement Regarding Marital Status

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0021

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Statement Regarding
Marital Status

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Employee's SS No.:
Employee's Name:

Paperwork Reduction Act 1 Privacy Act Notices
The Railroad Retirement Board is authorized to collect the
information on this form under Section 7(b)(6) of the
Railroad Retirement Act of 1974. The information will be
used to determine entitlement to benefits under this Act.
You are not required to provide this information. However,
your failure to do so may result in loss of benefits for the
applicant. Your cooperation in furnishing the information
is, therefore, very much appreciated.
We estimate this form takes a n average of 15 to 20
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 comments regarding
t h e accuracy of our estimate o r a n y other aspect of t h i s
form, including suggestions for reducing completion time, to
Chief of Information Resources Management, Railroad
Retirement Board, 844 North Rush Street, Chicago, Illinois
60611-2092.

INSTRUCTIONS: Unless you are told to skip and go to another item, all questions must be answered or marked "Unknown."
Type or print legibly in ink. If you need more space than is provided to answer a question, use ltem 15, Remarks, for this purpose.

1 Your Full Name

Name at Birth (If Different)
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Name of Marriage Partner

a
a

Did you ever live with anyone else as husband and wife?

a Name of Person

Yes -Go to Item 3a
No-Gotoltem4

Kind of Relationship (Ceremonial, etc.)
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How Relationship Ended

Date Relationship Started

Date and Place Relationship Ended

b Name of Person

Kind of Relationship (Ceremonial, etc.)
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Date Relationship Started

)

4

Date and Place Relationship Ended

How Relationship Ended

1 Did the person you were living with ever live with anyone else as husband
and wife?

a Name of Person

1

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II
5

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a

Yes -Go

to Item 4a
d

No-

1

Go to Item 5

Kind of Relationship (Ceremonial, etc.)

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.b Nameofperson
Date Relationship Started

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Kind of Relationship (Ceremonial, etc.)

How Relationship Ended

Date and Place Relationship Ended

Enter when and why you and the marriage partner separated.

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Continued

Form G-237 (05-08) Destroy prior editions

a Yes
a Noa Yes
a No-

a Did the marriage partner ever attempt to end your marriage by divorce
or annulment proceedings?

b Were you served with a notice of such proceedings?

-Go to Item 6b

Go to ltem 7
-Go to Item 6c

Go to Item 6d

c Enter the City and State where the notice was served.
Go to ltem 7

,

Month

d Enter when and how you learned of the attempt to end your marriage.

Year

-

Enter why you know or believe that your marriage to the marriage partner was or was not terminated by divorce or annulment.

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a Yes -Go to Item 8b
a No- Go to Item 9

8 a To your knowledge, is the marriage partner deceased?

1b

Enter the marriage partner's date and place of death.

a Yes

a Do you know where the marriage partner can be located?

-Go to ltem 9b

Go to ltem 9c

Ib

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Enter the marriage
- .partner's address below.
Street

State

City
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a Yes
a No-

c Do you know of any person(s) who knows where the marriage partner
can be located?

Id

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Go to ltem 10
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-Go to Item 9d

Go to Item 10

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Enter the name and address of such person(s).
Name

Address

Name

Address

10 Enter the following information about the marriage partner's closest blood relatives.
Name

Relationship

Address

II Where and when did you live after your separation from the marriage partner?
City or Town

Form G-237 (05-08)

County

Page 2

State

From
Month

To
Year

Month

Year

a Yes -Go

a Do you know of anyone who can furnish a statement about the places
where you lived after your separation from the marriage partner?

to Item 12b
Go to ltem 13a

a Yes
a No
I a K s -Go

b Will you have such person(s) complete Form G-238, Statement of
Residence, and forward it to the Railroad Retirement Board?

Do you know where the marriage partner lived after your separation?

No-

a Do you know of anyone (relatives or friends) who can furnish a state-

to Note and ltem 1 4 7
Go to Item 14a

es -Go to ltem 14b

a Noa Yes

ment about where the marriage partner lived after your separation?

b Will you have such person(s) complete Form G-238, Statement of

a

Residence, and forward it to the Railroad Retirement Board?

Go to Item 15

No

Remarks: Use this space 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 space to enter any additional information that you feel may be
important to include. If you need more space, use the back of this page.

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Certification: Failure to report or the making of a false or fraudulent report can result in criminal
both. I understand that civil and criminal penalties may be imposed on me for false or fraudulent statements, or for withholding
information to cause or prevent 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.

Date (Month, Day, Year)

Signature of person making statement
Signature (First Name, Middle Initial, Last Name)

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Mailing Address (Number and Street, Apt. No., P.O. Box, etc.)

City and State

1

ZIP Code

County (if any)

If the certification is signed by mark (X) in ltem 16, two witnesses who know the person signing must sign below, giving
their full addresses and daytime telephone numbers.

a. Signature of Witness

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b. Signature of Witness

Address (Number and Street, City, State and ZIP Code)

Address (Number and Street, City, State and ZIP Code)

Daytime Telephone Number
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Daytime Telephone Number

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(

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Page 3

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Form G-237 (05-08)