Form G-315 Student Questionnaire

United States of America
Railroad Retirement Board

Form Approved
OMB NO. 3220-0123

STUDENT QUESTIONNAIRE
INSTRUCTIONS
Refer to booklet G-316, Railroad Retirement Benefits for Students Age 18-19 and in Elementary or Secondary School, which
explains information you will need to answer many of the questions on this questionnaire. Also be sure to read the important
notices on page 3.
Based on your answer to a uestion, you may be told to skip to another item number, or even another section. Follow the
to" another item. These are designed to save you time by skipping items that do not apply to
instructions that tell you to
you. This helps you move through the form quickly, filling in only necessary information. If no "Go to" instructions are given,
answer the next ~temin order. Do not skip any items unless directed to do so.
Type or print legibly in ink. When applicable, enter an "Xuin the appropriate box.

"80

I CHILD'S STATEMENT REGARDING SCHOOL ATTENDANCE

SECTION A

2. Your Own Social Security Number

1. Your Name
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4.

3. RRB Claim Number
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[7 Yes - "X" the appropriate box below

For months you are age 18 through age 19, were you, are you, or
will you be, in full-time attendance at the elementary or high school
level?

Elementary School
Home School
N o - G o t o ltem 18

5. Do you authorize the school to disclose information about your
school attendance.. past,
and future to the Railroad
.
. present,
.
Retirement Board?
6. Enter the name and mailing address of the school or home school.

High School

Yes - Complete ltem 6
No - Go to ltem 18

8.

Enter the number of hours per week you were, are, or will be scheduled to attend the school
named in ltem 6. Note: If less than 20 hours per week, explain on a separate sheet of paper.
Yes - Complete ltem 9b
9. a. Did you attend, or are you attending, the school named in ltem 6
at the reauest of an emplover (paid to attend school)?
No - Go to Item 10
b. Enter the name of the employer.

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10. If you are studying at the high school level, enter the month and year of your expected date of
graduation. Otherwise, no to Item 11.

SEC'TION B

Month

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Year

1 *Chooseone* CERTIFICATION

11. a.

Is the school information provided in Section A, above, in
agreement with your school records?
11. b. Enter the correct information from your records.

(

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Yes - Go to Item 12
No - Complete Item 11b

12. Knowing that anyone making a false statement or representation of a material fact for use in determining a right to
payment under the Railroad Retirement Act commits a crime punishable under Federal Law, I certify that according
to this school's records, the information given above is true.
Name of *Chooseone* (Print)
Signature of *Chooseone*
Telephone Number

0
Name of School

)

Date

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RRB Form G-3 15 (04-06) Destroy Prior Editions

I SECTION C I STUDENT AGE 18 ATTAINMENT OR MONITORING INFORMATION

/ If you are also completing Form AA-19, Application for Child's Annuity, at this time, you may go to Section D. Otherwise,

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to Item
To update our records, for each item below, enter an " X in the appropriate boxes and complete any applicable
information.

13. a. Did you marry?
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Yes - Complete ltem 13b
No - Go to ltem 14a

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Month

b. Enter the Date of Marriage.
1

14. a. Did you file an application for social security benefits or
railroad retirement benefits based on an earnings record

1

/

Day

1

1

Year

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,

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Yes - Complete ltems 14b-c
No - Go to ltem 15a

b. Enter the name of the wage earner.
c. Enter the SSA or RRB Claim Ilumber.

1

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15. a. Do vou expect to earn more than the annual earnings
exe;npt amount(s) during the dates of school attendance
indicated in ltem 7?

b. Enter the total expected earnings for each calendar year.

16. a

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Yes - Complete ltems 15b-c

fl
- No - Go to ltem 16a

(Refer to the enclosed Form G-77 for the annual earnings exempt
amounts by calendar year.)

c.

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Month

Enter the month and year these earnings begin and end.

FROM
Year

Month

Year

Yes - Complete ltems 16b-c
No - Go to ltem 17

Did you work for an employer in the railroad industry?

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b. Enter the name of the employer.

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TO

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c.

Mo.

Enter the date work began and ended.

FROM
Day

TO

Mo.

Year

Day

Year

Yes - Read Note then go to Item 18
No or Not Applicable

17. Do you want to begin to receive your survivor benefits by
direct deposit to your financial institution?

NOTE: If answered "Yes," attach a voided check or copy of a savings account statement to this form.
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1 SEC'TION D I STUDENT CER'I'IFICATION SECTION
18. Knowing that anyone who makes any false or fraudulent statement or claim for the purpose of causing an award or
payment under Federal Law is committing a crime punishable under Federal Law, I certify that the school attendance
information furnished in Section A, and, if applicable, the entitlement information furnished in Section C of this form are
correct and Section B has been completed by my *Chooseone*.
I have read Booklet G-316, Railroad Retirement Benefits for Students Age 18-19 and in Elementary or Secondary
School, and I agree to immediately report any events which affect my entitlement as a student, to the RRB.
Student's Signature
Telephone Number
Date

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DEFINITION OF "FULL-TIME ATTENDANCE"
For Railroad Retirement Act purposes, students are generally considered to be in full-time attendance in elementary or secondary
school courses of at least 13 weeks duration with minimum attendance of 20 hours per week. High school level includes Technical and
Vocational courses. The program must be in accordance with the law of the State or other jurisdiction in which the students reside.
This includes enrollment in: (1) a public, private, or religious educational institution; (2) an independent study program administered by
the school district in which the student resides; or (3) home school elementary or secondary education. This definition agrees with the
Social Security Act definition of full-time student.
PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICE
This notice is given under the Paperwork Reduction Act 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) the law which allows us to ask for the information;
2) 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;
3) the reason why the information is requested; and,
4) the persons, organizations, and agencies to which we may release the information without your permission.
The RRBJsauthoriy for requesting this information is Section 7(b) of the Railroad Retirement Act (RRA) 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. Some of the information
may have an effect on the amount of benefits which we can pay.
Although the information we request is almost never used for any purpose other than the payment of benefits under the RRA, the RRB
does have the authority to release the following information to the indicated individuals, organizations, andlor agencies without your
approval:
1) An attorney, the Office of the President, a Congressional office, a labor union, or to the Department of State's embassy or
consular offices if they allege to be representing you at your request.
2) 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.
3) 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.
4) lnformation (including medical records) may be released to people or organizations who are working for the RRB.
5) The U. S. Treasury Department or Postal Service to issue payments and to investigate lost, forged, or stolen payments.
6) Your last employer to make sure that you are eligible to receive railroad retirement benefits and you continue to receive any
available medical benefits, and to any railroad employer (or to its insurance company) to make sure that you can receive any
private retirement or insurance benefits which may be offered by the employer.
7) The Social Security Administration, Centers 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 determihe if
you can receive benefits from their organizations and if any previous benefits were paid incorrectly.
8) The Internal Revenue Service or to State and local taxing authorities for figuring your taxes and for use in audits.
9) 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.
10) The General Accounting Office for audits and for collecting overpayments owed to the RRB or Social Security Administration.
11) The U.S. Department of Labor as required by the Federal Coal Mine and Safety Act.
12) In certain cases for law enforcement purposes and for court proceedings.
13) 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.
14) 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.
15) Professional Standards Review Organizations and State Licensing Boards when services provided by physicians or practitioners
suggests unethical or unprofessional conduct.
We estimate it takes an average of 15 minutes per response to complete, including the time needed 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 estimate or any other aspect of this form, including suggestions for reducing the completion time, to: Chief of lnformation
Resources Management, Railroad Retirement Board, 844 N. Rush Street, Chicago, IL 6061 1-2092.
COMPUTER MATCHING AND PRIVACY PROTECTION ACT NOTICE
I The Computer Matching and Privacy
Protection Act of 1988 requires the RRB to advise you that information you have provided may be
used, without your consent, in automated matching programs. These matching programs are a computer comparison of RRB records
with records kept by other Federal, state, or local governmental agencies. lnformation from these programs can be used to establish or
verify a person's eligibility for federally funded or administered benefit programs and for repayment of payments or delinquent debts
under these programs.

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RRB Form G-3 15 (04-06) Destroy Prior Editions