G-131 Authorization of Payment and Release of All Claims to a

United States of America
Railroad Retirement Board

AUTHORIZATION OF PAYMENT AND
RELEASE OF ALL CLAIMS TO A
DEATH BENEFIT OR
ACCRUED ANNUITY PAYMENT

Form Approved
OMB NO.3220-0031
Railroad Retirement Claim Number

Name of Deceased Individual

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 is needed to authorize payment of your share of an RRB benefit or
unpaid annuity to another eligible person. Although you are not required to furnish this information, your share of the RRB
death benefit or unpaid annuity cannot be paid to another person unless you complete and return the 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 5 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, includirlg suggestions for
reducing completion time, to Chief of Information Resources Management, Railroad Retirement Board, 844 North Rush
Street, Chicago, Illinois 60611-2092.
1. I have been informed of the approximate amount of the benefit payable in this case, and it is my desire to waive my
share of that benefit. Therefore, I hereby authorize the United States and its officers and agents, who are authorized
by law to certify and make such payments, to certify and pay my share of the benefit payable in this case, under the
provisions of the Railroad Retirement Act, to:
a. Name and Address

b.

Relationship to Deceased

2. In consideration of such certification and payment, I hereby release the United States and its officers and agents from
any and all claims which I may have against them for such accrued annuity or lump-sum death benefit, or by reason of
their certification and payment thereof.
a. Signature of Person Authorizing this Release
Date
I

Full Address (CityITown, State, and ZIP Code)

b.

Signature of Disinterested Witness

Date

G-13 1 (06-06) Destroy Prior Editions