Information Collection

Statement Regarding Contributions and Support

IC 33902 under ICR 201407-3220-006 · OMB 3220-0099.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0099 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form G-134 Statement Regarding Contributions and Support	Form
G-134 Statement Regarding Contributions and Support G-134 (10-05).pdf	Form

IC Title:

Statement Regarding Contributions and Support

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 222.41(4) 20 CFR 216.81

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	G-134	Statement Regarding Contributions and Support	G-134 (10-05).pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: RRB-22, Railroad Retirement, Survivor, and Pensioner Benefit System

FR Citation: 75 FR 43727

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	259	259
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.