Form G-88A.1 (03-13) G-88A.1 (03-13) Request for Verification of Date Last Worked

CURRENT
United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0005

Request for Verification of Date Last Worked – (Month/Year) Retirements
The following is a list of your former employees who have recently filed an application for either an age and service or a disability annuity with the Railroad
Retirement Board. The employees provided their Date Last Worked for your railroad; and, if applicable, the ending date of any Pay For Time Lost after the
actual date last worked. If the employees are filing based on age and service, they provided their Date Relinquished Rights to railroad employment. The dates
the employees provided on their applications are shown below. If a date is NOT correct, cross it out, enter the correct date above it, and add an attachment
explaining the correction. Otherwise, no further action is required.
Fax your correction and any attachments to the Retirement Benefits Division - RIS at (312) 751-7192.

BA
No

SSN

Payroll Name

Job Title

Dept-Div

Location

Date Last
Worked

Last Day of
Pay For Time
Lost, If Later
Than Date
Last Worked

Date
Relinquished
Rights, If
Applicable

CERTIFICATION: I understand that civil and criminal penalties can be imposed against me for false or fraudulent statements or for withholding information to misrepresent a fact
material to determining a right to payment under the Railroad Retirement Act. I certify that, to the best of my knowledge, the information which I have given is true, complete, and
correct.
Signature: _______________________________________________________________________
Title: ____________________________________________________________________________
Form G-88A.1 (03-13)

Date: _______________________________________