Form G-273a (06-06) G-273a (06-06) Funeral Director's Statement of Burial Charges

United States of America
Railroad Retirement Board

Form Approved

I Railroad Retirement Claim Number

FUNERAL DIRECTOR'S
STATEMENT OF
BURIAL EXPENSES

OMB No. 3220-0031

Employee's Social Security Number
Deceased Employee's Name
I

This form can be used in any case in which proof of payment of burial expenses is required. The G-273a MUST
be used whenever there are any funeral home charges which have not been paid.
The G-273a must be taken to the funeral home which handled the arrangements for the employee's funeral.
The form must be completed, signed, and dated by the funeral home director. The funeral home director
should return the completed form directly to the Railroad Retirement Board (RRB).
This report is authorized by law (45 U.S.C. 231f(b)(6)). While you are not required to respond, failure to do so
may prevent or delay payment of benefits.
'

YEAR

DAY

MONTH

1

Date of Death

+

2

Enter the total amount of your charges,
including cash advances, for this service.

+

3

List below all payments that you have received or expect to receive. Include payments from the Department of
Veterans Affairs, insurance policies, fraternal organizations and unions. Do not include the payment you expect from
the RRB. If paid by prearrangement, show the name of the person who made the prearrangement, not the insurance
company or financial institution making the final payment.
RECE~VED/EXPECTED
FROM

I
I

$

ADDRESS
AND TELEPHONE
NUMBER

I
I

BENEFICIARY
(IFANY)

I
I

DATE

AMOUNT
I

4

Is there still a balance due?

+

Yes
No

Go to ltem 5
Go to ltem 7

5

Has any person or organization taken responsibility
for the burial expenses?

+

Yes
No

Go to Item 6
Go to Item 7

6

Give the name, telephone number, and address of the person or organization that has taken responsibility for the burial
expenses.

................................................................................................................................................

Name

1

Address

Area Code

Telephone Number

1

I

United States of America
Railroad Retirement Board

7

Form Approved
OMB No. 3220-0031

Has any other funeral home furnished services in
connection with the deceased employee's burial?

Yes

+

Go to ltem 8

No

Go to Item 10

8. Give the name, telephone number, and address of the other funeral home that furnished services.

---------------------------------------------------------------------

Name
I

Address

'

9. Are the expenses for the funeral home listed in
ltem 8 included in the total in ltem 2?

Yes

+

No

If there are outstanding funeral home expenses, and the payment is assigned to the funeral home or the funeral home
applied for the payment, the payment will be deposited directly into the funeral home's account at the bank, savings and
loan, credit union or other financial institution. Either complete the following items or write "void" across a blank check
and attach it to this form.
10 Has the payment been assigned to the funeral home or
has the funeral home applied for the payment?

1

11 Print the name of your financial institution.

I

Go to Item 11
Go to Item 17

Yes
No

+

I

Telephone Number

Area Code

+

12 Enter the telephone number of your financial institution.

I

I

13 Enter the 9-digit routing transit number of your financial institution.
14 Enter the account number.

+

15 Enter the type of account for the above
account number.

+

1 1

Checking
Savings
I

Remarks

Page 2

Form Approved
OMB No. 3220-0031

United States of America
Railroad Retirement Board

17 CERTIFICATION OF FUNERAL DIRECTOR

I am an authorized funeral director and prepared for burial or buried the body of the employee named at
the top of this form.
I understand that this statement may be used in connection with an application for benefits payable
under the Railroad Retirement Act.
If the payment I receive from the RRB is greater than the unpaid expenses, I will either return the
payment or refund the excess to the RRB.

1
Print Name
Title
I

I

Date

I

Area Code

II

Telephone Number

PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICES

The Railroad Retirement Board (RRB) is authorized to collect the information on this form under section 7 (b) (6) of the
Railroad Retirement Act. The information asked for on this form is needed to determine eligibility for reimbursement for the
payment of burial expenses incurred by your funeral home. Although you are not required to furnish this information, no
payments can be made unless you complete and return this form.
A complete listing of the persons, organizations and agencies to which the information you give us may be released is
available at any office of the RRB.
We estimate this form takes an average of 10 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 OlMB 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 6061 1-2092.

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