G-346sum (proposed Employee's Certification Summary

PROPOSED

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0140

(Only printed if the application being filed is for a spouse annuity and the employee application is not being
filed at the same time and the entry on the Summary screen is equal to "V. '?

EMPLOYEE'S CERTIFICATION
INSTRUCTIONS
The following information was either supplied by or veri'fied by you. Review the information for accuracy and
notify the Railroad Retirement Board (RRB) immediately and no later than 30 days from the date of this
summary if there are any errors.
EMPLOYEE INFORMATION
1 Railroad Retirement Claim Number
2 Employee's Social Security Number
3 Employee's Name
YOUR MARRIAGE INFORMATION
4 I am currently married to (Spouse's Name).

5

I was not married before my current marriage.

(Printed if previously married question is
answered "Yes." Prefilled from employee
application.)
(Printed if previously married question is
answered "No." Prefilled from employee
application.)

6 The following is a list of my marriages before my current marriage.
Date Began

Spouse's Name

Ended by

Date Ended

99/99/9999

xxxxxxxxxxxxxxx

xxxxxxxxxxx

99/99/9999

(Printed if previously married question is answered "Yes." Prefilled from employee application.)

RELINQUISHMENT OF RIGHTS BY DISABILITY ANNUITANTS AND CERTIFICATION
7 I recognize that my spouse may not begin to receive an annuity while I hold rights to return to work for a
railroad employer. I authorize the RRB to relinquish any rights I may have to return to work for a railroad
employer. Based on this authorization, my rights will be relinquished if my spouse becomes entitled to a
spouse's annuity. I understand this authorization remains in effect unless I revoke it in writing.
CERTIFICATION
This information is certified by you to be true and correct to the best of your knowledge. You have been
informed and you acknowledge that making a false or fraudulent statement or withholding information, in
order to receive benefits from the Railroad Retirement Board, is a crime which is punishable under Federal
law which may include, fines, imprisonment or both.

Paperwork Reduction Act and Privacy Act Notices
The Railroad Retirement Board is authorized to collect the information on this form by Section 7(b )(6) of the
Railroad Retirement Act. This information' is needed to determine your spouse's or former spouse's
entitlement to benefits under the Railroad Retirement Act. You are not required to provide the information
RRB Form G-346sum (xx-xx)

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0140

requested by this form, however, your failure to do so may result in your spouse or former spouse not
receiving these benefits.
We estimate this form takes an average of 5 minutes 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 Street, Chicago, IL 60611-2092.

RRB Form G-346sum (xx-xx)

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