Notice of Information Needed in Claim under Railroad Retirement Act

1
NOTICE OF INFORMATION
NEEDED IN CLAIM UNDER
RAILROAD RETIREMENT ACT

1. RRB CLAIM NUMBER

2. EWIPLOYEE'S SOCIAL SECURITY NO.

3, EMPLOYEE NAME

The items checked below are required to process your claim under the Railroad Retirement Act.
Do not furnish any document described below unless it is checked.
Be sure to read the second page of this form. It contains information about obtaining the necessary proof(s).

PROOF OF YOUR AGE.

[7 PROOF OF AGEOF

.

PROOF OF YOUR MARRIAGE TO THE EMPLOYEE.

[7 PROOF OF MARRIAGE OF

.

[7 PROOF OF YOUR DIVORCE FROM THE EMPLOYEE.
[7 PROOF OF DIVORCE OF

.

[7 PROOF OF YOUR RELATIONSHIP TO THE ENIPLOYEE.
[7 PROOF OF RELATIONSHIP OF

/

PROOF OF ACTIVE DUTY MILITARY SERVICE, IF ANY.
PROOF OF DEATH OF THE EMPLOYEE.
PROOFOF DEATHOF

1

~

1
1

.

.

PROOF OF PAYMENT OF THE EMPLOYEE'S BURIAL EXPENSES.
PROOF OF APPOINTMENT AS LEGAL REPRESENTATIVE OF THE EMPLOYEE'S ESTATE.

(7 YOUR SOCIAL SECURITY NUNIBER.
(7 SOCIAL SECURITY NUMBER OF

.

DIRECT DEPOSIT INFORMATION.

[7 PROOF OF PUBLIC SERVICE PENSION OR NON-COVERED SERVICE PENSION.
PUBLIC SERVICE PElVSlON OFFSET VERIFICA1-ION.

[7 EMPLOYER IDENl'IFICATION NUMBER (EIN).

BE SURE TO READ THE SECOND PAGE OF THIS FORM.
IT CONTAINS INFORMATION ABOUT OBTAINING THE NECESSARY PROOF(S)

TYPES OF PROOFS
PROOF OF AGE - The best proof is a certified copy of the civil or church record of the date of your birth made at
or near the time of birth. Such proof should be submitted unless it can be shown that these records do not exist.
In the latter case, you should submit the next oldest record you can locate, such as an insurance policy, fraternal
record, or other document that shows (a) your name and your date of birth or age and (b) the date the record was
made, which must be more than five years before the date on which you file an application for an annuity.
PROOF OF MARRIAGE - The best way to prove a marriage is by furnishing a certified copy of the public marriage
record, a certified copy of the church marriage record or the original marriage certificate. If none of these proofs is
obtainable, give the reason and submit a statement from the clergyman or official who performed the marriage
ceremony. When proving a marriage to other than the railroad retirement employee, provide the full name of the
spouse, date and place of the marriage, when the marriage ended, and the former spouse's social security
number.
PROOF OF DIVORCE - Such proof may be the original divorce decree, a certified copy of the divorce decree or
an abstract certification of the divorce decree.
PROOF OF RELATIONSHIP - The preferred proof of relationship is a certified copy of a civil or church record of
such person's birth. If neither of these proofs is obtainable, give the reason and submit another record such as a
hospital birth record or certificate, a Bible or family record, a school record or the affidavits of two disinterested
individuals who have knowledge of the relationship. Any evidence which is submitted to show the relationship of a
brother or sister must show the claimant's name, the name of the his parents, and must reflect the parent and child
relationship. If the evidence submitted as proof of marriage or relationship also indicates the age or date of birth of
the individual to whom the evidence pertains, separate proof of age is not required.
PROOF OF MILITARY SERVICE - Acceptable proof may be the original certificate of discharge, or any official
military record that shows the dates of your active service, or a certified copy of the original document.
PROOF OF DEATH - Acceptable proofs of death include a certified copy of the death certificate, which may be
obtained from the city, county, or State Department of Health or Registrar of Vital Statistics in the state where
death occurred; or a statement of death completed by the funeral director on RRB Form G-273a, Funeral Director's
Statement of Burial Charges.
PROOF OF PAYMENT OF BURIAL EXPENSES - Acceptable proofs that burial expenses were paid include the
original itemized receipted bill or certified copy of it showing name of person or organization who paid the burial
expenses; or a statement of burial expenses completed by the funeral director on RRB Form G-273a, Funeral
Director's Statement of Burial Charges.
PROOF OF APPOINTMENT AS LEGAL REPRESENTATIVE - A person claiming benefits as legal representative
of an estate must submit evidence of the court appointment. If appointment was made more than one year ago,
the letters must carry the court's certification that they are still in full force and effect.
SOCIAL SECURITY NUMBER - Acceptable proofs include a copy of the social security card, a letter from the
Social Security Administration, or other proof for social security number.
DIRECT DEPOSIT INFORMA'I'ION - The best proof is a specific document from your financial institution. 'This
could include a voided check, Form Sf-1199a, Direct Deposit Sign-up form, or other document from your financial
institution that includes the 9-digit routing number, your name, and account number. Failure to provide this
information could result in a delay of payment.
PROOF OF PUBLIC SERVICE PENSION OR NON-COVERED SERVICE PENSION - Acceptable proofs should
include effective dates and current amount of pension.

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PUBLIC SERVICE PENSION OFFSET VERIFICATION If your Public Service Pension employer was a State or
Local government agency, acceptable proof is a letter from this employer indicating that FICA (Social Security)
taxes were withheld from the last 60 months of your employment, including your last day of employment.
EMPLOYER IDENTIFICATION NUMBER (EIN) - This is a 9-digit number that can be found on Form W-2 or
obtained from your last nonrailroad employer.