Form G-139 Statement Regarding Contributions and Support of Childre

UNITED
STATES
OF AMERICA
RAILROAD
RETIREMENT
BOARD

FORM
APPROVED

OM6 NO. 3220-0195

DO NOT WRITE IN THIS SPACE
OFFICIALLY FILED

STATEMENTREGARDING
CONTRIBUTIONS
AND SUPPORT
OF CHILDREN

MONTH

1

DAY

I

OFFICE NUMBER

YEAR

8

I
APPROVED

The information requested on this form is authorized by section 7(b)6 of the Railroad Retirement Act. The information asked for
in this form is necessary to determine entitlement to benefits under the Railroad Retirement Act. You do not have to provide the
information requested. However, if you fail to do so, we may not be able to pay benefits. We estimate this form takes an
average of 60 minutes per response, 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 the accuracy of our
estimates or any other aspect of this form, including suggestions for reducing the completion time to: Chief of Information
Resources Management, Railroad Retirement Board, 844 North Rush Street, Chicago, Illinois 60611-2092.
INFORMATION REQUESTED ON THIS FORM IS FOR THE 12-MONTH PERIOD:

AND ENDED

WHICH BEGAN

Type or print all answers legibly in ink. If you need more space than is provided to answer a question, use Section 6 for this
purpose. If you do not know the answer to a question, print "unknown" in the space provided for the answer.
When entering dates, always use numbers. Also, be sure there is one number in each box. For example, you would enter
January 1,2004, as:
MONTH

1

DAY

I

YEAR

If you are completing this form on behalf of someone else, you must answer each question as it applies to the applicant.

Check the information provided for Items 1 through 5 for accuracy.
b If the information is correct, go to Itern 6.
b If the information is not correct, cross out the incorrect information and enterthe correct information above it.
b If the information is missing, fill it in.

v
1 EMPLOYEE'S NAME
Z

F O
W F

$3
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-

5
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-

I
a

W
G
30

2 EMPLOYEE'S SOCIAL SECURITY NUMBER
3 EMPLOYEE'S RAILROAD RETIREMENTCLAIM NUMBER
4 CHILD'S NAME

5 CHILD'S RELATIONSHIPTO EMPLOYEE
6 PRINT YOUR FULL NAME

OE

A

7 YOUR RELATIONSHIP To THE CHILD

-

+

+

-

-

Form G-139 (04-05) Destroy Prior Editions

v

w

W

8

--

Enter the total amount of the employee's income during the 12-month period.
If you do not know, enter "Unknown."

--+$

Enter the amount the employee contributed to the child's support
during the 12-month period. (Contributions may be in cash or kind,
such as living renf-free in a house which the employee owned.)

-+$

10 Enter the frequency of contributions (weekly, monthly, irregularly, etc.).

11 Enter the date the employee last contributed.
k
[L

B
3

V)

- -

v

12 If the employee's contributions were irregular, varied in amounts, or stopped before the end of the 12-month period,
explain here. If you need more space, continue in Section 6.

-

13 Enter an " X in the appropriate box:
Did the employee and child live together in the same household --+
during the 12-month period?

a
a

Yes
No

14 Enter below information about anybody (other than the employee) who, during the 12-month period, either:
lived with the child, or
contributed to the support of the child or to the support of the household in which the child lived. Include as
contributions:
Payments for room and board
a Cash given for support

Payments for household expenses (clothing, insurance premiums, Medical expenses, gifts, etc.)
cn
+

If any of the contributions were for the support of other members of the household, use Section 6 or a
separate sheet to provide details.

W
Z

$
i
Z
a

Where applicable. enter "None."

82

1

NAME

RELATIONSHIP
TO CHILD

TOTAL AMOUNT
OF CONTRIBUTIONS DURING
THE PERIOD M0MI-I

DATE AND AMOUNT OF
LAST CONTRIBUTION
DAY

$

$
$
A
Form G-139 (04-05)

Page 2

YEAR

AMOUNT

$

I

$
$

15 Did the child have wages or income of his or her own?
A

v
a
I

V)

z

a

a

Yes - How much per month? $

16 Was the child claimed as a dependent on a Federal tax return during the 12-month period?

D Yes - Enter below the person's name and relationship to the child.

D No

0

5

lx

No

Name:
Relationship:

17 Enter the following information about any other income the child received during the 12-month period.
DATE THE CHILD LAST RECEIVED
INCOME AND AMOUNT
NET INCOME

SOURCE OF INCOME

MONTH

DAY

YEAR

AMOUNT

Social Security Benefit
(Include SSI Payment)
Child Support Payments

Stocks, bonds, securities, etc.

Other (Explain)

,

$
$

$

1 ,

$
$

$

$

$

$

A
Page 3

Form G-139 (04-05)

18 This section is to be used for 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.

I9 1 understand that civil and criminal penalties may be imposed against me for false or fraudulent statements,

or for withholding or misrepresenting information in order to receive benefits from the Railroad Retirement
Board. I certify that the information provided to the Railroad Retirement Board on this statement is true,
complete, and correct to the best of my knowledge.

Z

o
5

2
LL.
k2
2

A

SIGNATURE
(First Name, Middle Initial,
Last Name)

+

DATE

+

20 If this certification is signed by mark ("X) in Item 19, two witnesses who know the person signing must sign below,

giving their full addresses and daytime telephone numbers.
a. Signature of Witness

b. Signature of Witness

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

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

Daytime Telephone Number

Daytime Telephone Number

(

Form G-139(04-05)

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