Form G-315A Statement of School Official

Form Approved
OMB NO.3220-0123

United States of America
Railroad Retirement Board

Statement of School Official
The Railroad Retirement Board's (RRB) authority for requesting this information is contained in Section
7(b)(6) of the Railroad Retirement Act (45 U.S.C. 231f(b)(6)). While you are not required to respond, your
cooperation in promptly completing and returning this form will be appreciated. Failure to do so may result in
nonpayment of RRB benefits to the student.
We estimate this form takes an averageof 3 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 the accuracy of our estimate
or any other aspect of this form, including suggestions for reducing completion time, to Chief of Information
Resources Management, Railroad Retirement Board, 844 North Rush St., Chicago IL 6061 1-2092.

Section A

I Full-Time Attendance Information Provided By 'The Student
I

1. Student's Name
2.

Student's Social Security Number

3. Type of school the student was
attending, is currently attending, or will
resume attending within four months

Elementary School
High School Level (Including Technical and Vocational)
Home School

I

4.

Name of the school

5. Student dates of full-time attendance at the school named in ltem 4

Began

Ended

Month and Year

Month and Year

6. Number of hours per week the student was, is, or will be scheduled to
attend the school named in ltem 4

Scheduled
Hours Per Week

7. Expected month and year of graduation date, if the student was, is, or
w~llbe studying at the high school level

Month and Year

Certification of School Official
The School Official is to enter an "X" in the appropriate boxes. Type or complete legibly in ink
any requested information.
Yes - Go to ltem 13
8. Is the information provided by the student in Section A, in agreement
with your records?
NO Go to Item 9
yes - G o to ltem 10
9. Was the student ever in attendance at your school on a full-time
basis?
110- GOto ltem 13
Ended
Began
10. Enter the student's last period of full-time attendance at your
Month and Year
Month and Year
school.

Section B

-

I

Yes
11. Is, or was, the student scheduled to attend your school for 20 or more
hours per week?
No
12. If the Railroad Retirement Board office entered a graduation month and year in
Section A, ltem 7, that does not agree with your records, enter the correct month

Month and Year

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.
Signature of School Official
Telephone Number

I

Title

(
Date

1
-

RRB Form G-3 15A (0 1-06) Destroy Prior Editions

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0123

SCHOOL OFFICIAL'S NOTICE OF CESSATION OF
FULL-TIME SCHOOL ATTENDANCE
Retain this form in your files for use in notifying the Railroad Retirement Board if the student named
below changes plans and does not return to full-time attendance for a new school term or ceases
full-time attendance for a reason other than graduation.
The information requested on this form is needed to terminate student benefits timely. The Railroad Retirement
Board's (RRB) authority for requesting this information is contained in Section 7(b)(6) of the Railroad Retirement Act
(45 USC 231f(b)(6)). While you are not required to respond, your cooperation in promptly completing and returning
this form will be appreciated.
We estimate this form takes an average of 2 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 the accuracy of our estimate or any other aspect of this form,
including suggestions for reducing completion time, to Chief of Information Resources Management, Railroad
Retirement Board, 844 North Rush St., Chicago IL 60611-2092.
When an event listed in Item 7, below, applies, please return this completed form by mail or facsimile to:

Facsimile Number:

1. Student's Name
2.

Student's Social Security Number

3.

Railroad Employee's Name

4.

RRB Claim Number

5.

Name of School

CERTIFICATION OF SCHOOL OFFICIAL
6. Enter the date the student identified above ceased to be a full-time
student at your school.

Month

Day

Year

-

7. Check the appropriate box:
Reason the school
attendance ended.

1. Suspension or expulsion
2. Withdrawal
3. Change to part-time status
4. Failure to continue in full-time attendance at start of new term
5. Transfer to full-time attendance at another school
6. Other:

8. 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 institution's records, the information given above is true.
Signature of School Registrar
Telephone Number
Date

RRB Form G-3 15A1 (0 1-06) Destroy Prior Editions