G-315A.1 (proposed School Official's Notice of Cessation of Full-Time Schoo

PROPOSED

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.
Paperwork Reduction Act and Privacy Act Notices
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:
Railroad Retirement Board

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

Month

Day

Year

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.
Telephone Number
Printed Name of *ChooseOne*

(
Signature of *ChooseOne*

)

Date

RRB Form G-315A1 (xx-xx) Destroy Prior Editions