Form G-346 (06-08) G-346 (06-08) Employee's Certification

1

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0140

DO 'NOT WRITE IN THIS SPACE

Employee's Certification

REVIEWED BY:
I

Type or print all answers legibly in ink. If you need more space than is provided to answer a question, use ltem 7, Remarks
for this purpose. If you do not know the answer to a question, print "unknown" in the space provided for the answer.
Some items in this application will not apply to you so you will not need to answer them. Based on your answer to a
question, you may be told to skip to another item number. Follow the instructions that tell you to "Go to" another item.
These are designed to save you time and help you move through the report form quickly, filling in only necessary
information. If no "Go to" instructions are given, answer the next item in order. Do not skip any items unless directed to do
SO.

-

Identifying Information

a

Check the information entered by the Railroad Retirement Board (RRB) for Items 1 through
3 for accuracy.
> If the information is correct go to item 4.
> If the information is not correct, cross out the incorrect information and enter the correct information above it.
If the information is missing, fill it in.
Employee
1 RAILROAD RETIREMENT CLAIM NUMBER b
Identification

>

1

I

2 SOCIAL SECURITY NUMBER

1 3 NAME

I

I

I

I

I

I

I

T o
Marriage Information
Spouse's
Name

4 Print the name of the person to whom you
are currently married.

Previous
Marriages

5 Enter an " X in the appropriate box:
I was married before my current marriage.

I

Yes
No

-

Go to Item 6
Go to Section 4

6 Print the following information about your previous marriages, beginning with your most recent one. If
you need more space, continue in ltem 7, Remarks.
Marriage Ended
Marriage Began
Spouse's
Place
Place
Name
Date
How
Date
(City and State)
(City and State)
(Check One)

Death

OD'lvorce
Annulment
Death
Divorce
Annulment
Death

United States of America
Railroad Retirement Board

-

Form A ~ ~ r o v e d
OMB No. 3220-0140

Page 2

Remarks
7 This section is to be used for the continuation of answers to other items. Be sure to include the item
number at the beginning of the answer you wish to continue. You may also use this space to enter any
additional information that you feel may be important to include.

Remarks

I

Relinquishment of Rights by Disability Annuitants and Certification
Relinquishment of
Rights

I

~

e

8 1 recognize that my spouse ma not begin to
railroad employer. By signing t is statement, I authorize the
return to work for a railroad employer. Based on this
spouse becomes entitled to a spouse's annuity. I
I revoke it in writing.

hts to return to work for a
any rights I may have to
be relinquished if my
in effect unless

Y,

1

r

t

i

f

i

c

committing a crime which is punishable under Federal law.

a

t

i

SIGNATURE
(First Name, Middle Initial, Last Name)

Area Code

DAYTIME TELEPHONE NUMBER t

Telepho~eNumber

know the person signing must

Address (Number and Street, City, State, and Zip Code)

Daytime Telephone Number: (
b Signature of Witness

)

Address (Number and Street, City, State, and Zip Code)

Daytime Telephone Number: (

I

o

1

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 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.