3220-0099

OMB NO. 3220-0099

Justification

Statement Regarding Contributions and Support

RRB Form G-134

1. Circumstances of information collection - Dependency on the employee for at least one-half support can affect entitlement to a survivor annuity and can affect the amount of both spouse and survivor annuities.

Entitlement to a survivor annuity - Dependency on the employee for at least one-half support at the time of the employee's death can affect eligibility for a survivor annuity provided for under section 2 of the Railroad Retirement Act (RRA). This occurs when the survivor is a parent of the deceased employee. The requirement is prescribed in 20 CFR 216.81(a)(3) and 222.41(a)(4).

Amount of spouse or survivor annuity - Under certain circumstances, a portion of an annuity payable to a spouse or widow(er) is subject to an offset for a public service pension. A public service pension is any benefit payable to an individual because of their employment with a Federal, State, or local unit of government. Dependency on the employee may negate the annuity offset. Sections 4(a)(1) and 4(f)(1) of the RRA provide that the annuity amount of a spouse, divorced spouse, and survivor shall be an amount equal to the amount a beneficiary would receive if entitled under the Social Security Act. Section 7(a)(1) of PL 97-455 amends Sections 202(b), (c), (e), (f), and (g) of the Social Security Act, to specify when half support will negate the public service pension offset for a wife, husband, widow, widower, and mother or father. In addition, the requirement is prescribed in 20 CFR 404.408(a).

Restored Amount - A Tier II restored amount is payable to a widow(er) whose annuity is reduced for receipt of an employee annuity under the RRA provided either the employee or the widow(er) had ten years of creditable railroad service prior to January 1, 1975. In addition, a widow(er) must have been dependent on the railroad employee for at least half of his/her support in the year prior to the employee’s death or, if earlier, at the time the spouse's annuity began. This requirement is prescribed in 20 CFR 228.52(c).

2. Purposes of collecting/consequences of not collecting the information - Form G-134, Statement Regarding Contributions and Support, obtains evidence of the claimed support from an applicant during a specific 12-month period. Without the information obtained by the G‑134, the Railroad Retirement Board (RRB) cannot determine if an applicant meets the one-half support eligibility requirement.

The RRB proposes no changes to Form G-134.

Form G-134 is designed for self-administration. Other options are in-person field office or itinerant point assistance or telephone interview. The RRB prefills the beginning and ending dates of the period in question, as well as the identifying information in Items 1-6. When a G‑134 is completed outside the benefit application process, Form G-242, Notice of Information Needed in Claim Under the Railroad Retirement Act, and its cover letter, Form RL-57A-F, Letter Requesting Applicant to Furnish Evidence, are transmitted with the G-134 to request any proofs needed to complete the claim.

Form G-134 is similar to Form SSA-760-F4, OMB No. 0960-0001.

3. Planned use of improved information technology or technical/legal impediments to further burden reduction - None planned due to low volume (100 responses annually).

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 since the information is solicited only once.

7. Special Circumstances - N.A.

8. Public Comments/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 26469 of the May 8, 2014, Federal Register. No requests for further information or comments were received.

9. Payment or Gifts to Respondents - N.A.

10. Confidentiality - Privacy Act System of Records, RRB-22, Railroad Retirement, Survivor, and Pensioner Benefit System - RRB. 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 - There are no questions of a sensitive nature.

12. Estimate of respondent burden - The current estimated burden is unchanged as follows:

Current Burden

Form Number	Annual Responses	Time (Minutes)	Burden (Hours)
Form G-134 With assistance Without assistance	75 25	147 180	184 75
Total	100		259

13. Estimate of annual cost burden to respondents or record keepers - N.A.

14. Estimated cost to Federal Government - N.A.

15. Explanation for changes in burden - N.A.

16. Time schedule for data collection and publication -The results of this collection will not be published.

17. Request to not display OMB expiration date - The G-134 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 authorization to not display the expiration date on the form.

18. Exceptions to Certification Statement - None

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