3220-0183

OMB NO. 3220-0183

Justification

Statement of Claimant or Other Person

RRB Form G-93

1. Circumstances of information collection - Pertinent information and proofs must be furnished to the Railroad Retirement Board (RRB) to support an application for an annuity under Section 2 of the Railroad Retirement Act (RRA) or for unemployment benefits under Section 2of the Railroad Unemployment Insurance Act (RUIA). The RRB uses the information and/or proofs obtained, to help determine an applicant's entitlement to benefits.

¶In some cases, special circumstances require an applicant, or another person who has knowledge of the facts relating to the applicant's eligibility for an annuity or benefits, to provide a written statement supplementing or changing information previously provided by the applicant.

• Under the railroad retirement program the statement may relate to a change in an annuity beginning date; date of marriage or birth; railroad or non-railroad employment; an applicant's request for reconsideration of an unfavorable RRB eligibility determination for an annuity; or various other matters. The procedure for providing information for an RRA annuity determination is prescribed in 20 CFR 217.

• Under the railroad unemployment and sickness programs the statement may involve a variety of different situations relating to an RRB eligibility determination for unemployment and sickness benefits. The procedure for providing information for an RUIA benefit determination is prescribed in 20 CFR 320.

2. Purposes of collecting/consequences of not collecting the information - In certain cases, to support an application for an annuity or unemployment benefits, the RRB needs to obtain, from applicants or other persons, supplemental or corrective information that is not requested by other RRB forms. In other cases, the applicant or another person who has knowledge of the facts may want to provide a written statement supplementing or changing information previously submitted. Form G-93 is used for these purposes.

Form G-93, Statement of Claimant or Other Person, is used by the RRB to correct information previously reported by an applicant or other person, and/or to obtain any additional information needed to help determine applicant eligibility for an RRA annuity or RUIA benefits not requested by other RRB forms. Form G-93 is generally completed by a respondent in an RRB office and in the presence of an RRB representative.

Form G-93 requests the following information:

• The name of the railroad employee,

• name of the claimant (if other than the railroad employee),

• relationship to the claimant of the person making the statement,

• social security number of the railroad employee,

• RR Retirement Annuity Claim Number (if different from social security number), and

• name of the person making the statement (if other than the claimant).

The signature block requests the signature, mailing address, telephone number, and date on which the statement is completed. 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 40658 of the July 10, 2012, 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. In accordance with OMB Circular M-03-22, a Privacy Impact Assessment for this information collection was completed and can be found at http://www.rrb.gov/pdf/PIA/PIA-BPO.pdf.

11. Sensitive questions - N.A.

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

Current Burden

Form Number	Annual Responses	Time (Minutes)	Burden (Hours)
G-93	900	15	225

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

14. Estimate 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

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