3220-0183

OMB NO. 3220-0183

Justification

Statement of Claimant or Other Person

RRB Form G-93

1. Circumstances of information collection - To support an application for an annuity under Section 2 of the Railroad Retirement Act (RRA) or for unemployment benefits under Section 2 of the Railroad Unemployment Insurance Act (RUIA), pertinent information and proofs must be furnished to the Railroad Retirement Board (RRB) so that the RRB can determine an applicant's entitlement to such benefits. In some cases, special circumstances require an applicant or other person(s) having knowledge of the facts relating to the applicant's eligibility for an annuity or benefits to provide written statements supplementing or changing information previously provided by the applicant. Under the railroad retirement program these statements may relate to changes in the annuity beginning date(s), dates for marriage(s), birth(s), railroad or non-railroad employment, an applicant's request for reconsideration of an unfavorable RRB eligibility determination for an annuity or various other matters. Under the railroad unemployment and sickness programs, the statements involve a variety of different situations relating to RRB eligibility determinations for unemployment and sickness benefits.

The procedures pertaining to the providing of information for RRA annuity or RUIA benefit eligibility determinations are prescribed in 20 CFR 217 and 320 respectively.

2. Purposes of collecting/consequences of not collecting the information - Before the approval of Form G-93, the RRB had no standard form to obtain supplemental or corrective information from applicants or other persons for use in determining applicant eligibility for an RRA annuity or RUIA benefits. In the absence of such a form, RRB field offices used bond/tablet paper, or whatever other writing material was available at the time an informational statement was secured from an individual. These situations often led to improvisation by the field offices in the recording of the information provided and, in some cases, the omission of key applicant identifying information such as the railroad employee's social security number, the name and/or relationship of the person making the statement (if other than the applicant), or other such information occurred. The collection of information in this manner sometimes led to the accidental misfiling or the unintentional destruction of the information statement.

Form G-93, Statement of Claimant or Other Person, is the form utilized by the RRB to correct information previously reported by an applicant or to obtain information not requested by other RRB forms. Form G-93 is generally completed by a respondent in an RRB field office and in the presence of a field office staff representative.

The front side of Form G-93 requests the following information:

• The name of the railroad employee,

• Social security number of the railroad employee,

• name of person making the statement (if other than the railroad employee), and

• relationship of person making the statement to the railroad employee.

The signature block requests, in addition to the signature, the date on which the statement was completed, the telephone number of the person making the statement, and the person's address. If the signature is by mark ("X"), the signatures and addresses of two witnesses are also required.

Form G-93 is similar to Form SSA-795, Statement of Claimant or Other Person, OMB No. 0960-0045.

The RRB proposes no changes to Form G‑93.

3. Planned use of improved information technology or technical/legal impediments to further burden reduction – Not cost effective due to low volume.

4. Efforts to identify duplication - This information collection does not duplicate any other information collection.

5. Small business respondents - N.A.

6. Consequences of less frequent collection - Not applicable as the information is obtained only once.

7. Special Circumstances - None

8. Consultations outside the agency - In accordance with 5 CFR 1320.8(d), comments were invited from the public regarding the information collection. The notice to the public was published on page 7275 of the February 13, 2009, Federal Register. No comments were received.

9. Payments or gifts to respondents – None

10. Confidentiality - Privacy Act Systems of Record, RRB-21, Railroad Unemployment and Sickness Insurance Benefit System and RRB-22, Railroad Retirement, Survivor and Pensioner Benefit System.

11. Sensitive questions - N.A.

12. Estimate of respondent burden - The current annual burden for the collection is unchanged as follows:

Current Burden

Form #	Annual Responses	Time (Min)	Burden (Hrs)
G-93	900	15	225

13. Estimated annual cost to respondents or recordkeepers - N.A.

14. Estimated of cost to the Federal government - N.A.

15. Explanation for change in burden - N.A

16. Time schedule for data collections and publication - The results of this collection will not be published.

17. Request not to display OMB expiration date - Form G-93 is seldom revised. Given the costs associated with redrafting, reprinting, and distributing the form in order to keep the appropriate OMB expiration date in place, the RRB requests the authority to not display the OMB expiration date on the form.

18. Exceptions to Certification Statement - None