G-124 (Proposed) Statement of Marital Relationship

PROPOSED

United States of America
Railroad Retirement Board

Individual Statement of
Marital Relationship

Form Approved
OMB No. 3220-0021

RRB Claim No.:
Employee's SS No.:
Employee's Name:

Paperwork Reduction Act and Privacy Act Notices
The Railroad Retirement Board is authorized to collect the information
on this form under Section 7(b)(6) of the Railroad Retirement Act of
1974. The information will be used to determine entitlement to benefits
under this Act. You are not required to provide this information.
However, your failure to do so may result in loss of benefits for the
applicant. Your cooperation in furnishing the information is, therefore,
very much appreciated.
We estimate this form takes an average of 15 to 20 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 Street,
Chicago, Illinois 60611-1275.

Instructions: All questions must be answered or marked “Unknown.” Type or print legibly in ink. If you need more space than
is provided to answer a question, use Item 23, Remarks, for this purpose.

1 Your Full Name

3

2 Full name of person you were living with

a Starting with the time you began living together as husband and wife, enter the places you lived and the dates you lived
there, then check () whether you lived in each of the places together or separately. If you check “Lived Separately” also
answer Item 3b.
Lived
Lived
From
To
Town
State
Together
Separately
Month
Year
Month
Year
()
()

b Enter the reason(s) you did not live together continuously and the date(s).
Reason(s)

4

Did you have an understanding as to your relationship when you began living together?
If “Yes,” answer Items a and b.

To

From
Year
Month

Month

R Yes

R No

Year

a If it was in writing, furnish a copy; if it was not in writing, what did you say to each other about your living together?

b Was this understanding later changed? If “Yes,” describe the changes and when and
why they were made.

5

Did you have an understanding as to how long you would live together? If “Yes,” what did
you say to each other about how long you would live together?

Continued

R Yes

R No

R Yes

R No

Form G-124 (xx-xx) Destroy prior editions

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Did you have an understanding as to how your relationship could end? If “Yes,” what did
you say to each other on this subject?

R Yes

R No

7

Did you believe that your living together made you legally married? If “Yes,” why did you believe so?

R Yes

R No

8

Was there an agreement or promise that a ceremonial marriage would also be performed
in the future? If “Yes,” explain why the ceremony was not performed.

R Yes

R No

9

Were any children born of this relationship? If “Yes,” list below.

R Yes

R No

Name

Date of Birth

Place of Birth

10 a By what names were you and the person you were living with known?
Man's Full Name

Woman's Full Name

(1) Before you lived together.
(2) Since you lived together.

b If you both did not use the same last name after you began living together, state why.

11 After you started living together, were there any legal papers created with both your names
such as deeds, insurance policies, bank accounts or contracts signed? If “Yes,” list below.
Note: If you have copies of such documents, furnish them with this form.
Type of Document

Date Made

R No

Were you shown as the other's husband or wife?

12 Did you have joint business dealings with other persons or joint charge accounts in stores?

If “Yes,” give the name and address of such person or store and the date of the transaction.
Name of Person or Store

R Yes
R Yes

R No

R Yes

R No

R Yes

R No

R Yes

R No

Address

Date of Transaction

13 a How did you introduce the person you were living with to relatives, friends, neighbors, business acquaintances and others?

b How did that person introduce you to relatives, friends, neighbors, business acquaintances and others?

Form G-124 (xx-xx)

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14 How was mail addressed to you?
15 List below the names and addresses of any employers and neighbors who knew of your relationship.
Name

Address

a
b
c
16 List below your closest relatives (other than children) who knew of your relationship.
a Name

Relationship to you

Address

b Name

Relationship to you

Address

c Name

Relationship to you

Address

17 List below the closest relatives (other than children) of the person you were living with who knew of your relationship.
a Name

Relationship to person you were living with

Address

b Name

Relationship to person you were living with

Address

c Name

Relationship to person you were living with

Address

18 One or more of the employers, neighbors, and/or relatives shown above may be contacted regarding knowledge they may have of
your marriage. If you object to us contacting any of the above, please list their name(s) and give the reason(s) for your objection(s).
NAME

REASON

19 Did you ever live with anyone else as husband and wife? If “Yes,” complete Items a and b, below.
a Name of Person
Date Relationship Started

R No

Kind of Relationship (Ceremonial, etc.)
Date and Place Relationship Ended

How Relationship Ended

b Name of Person
Date Relationship Started

R Yes

Kind of Relationship (Ceremonial, etc.)
How Relationship Ended

Date and Place Relationship Ended
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Form G-124 (xx-xx)

20 Did the person you were living with ever live with anyone else as husband and wife?
If “Yes,” complete Items a and b, below.
a Name of Person
Date Relationship Started

R No

Kind of Relationship (Ceremonial, etc.)
Date and Place Relationship Ended

How Relationship Ended

b Name of Person
Date Relationship Started

R Yes

Kind of Relationship (Ceremonial, etc.)
How Relationship Ended

Date and Place Relationship Ended

Answer Item 21 if either of you had an earlier ceremonial or common-law marriage that is still in effect or that ended after you began living together.

21 At the time you began living together did you know that the earlier marriage was still in effect?

R Yes

If “No,” answer Items a and b, below.

R No

a When and how did you first learn that this marriage was still in effect?

Month

Day

Year

b When and how did the person you were living with first learn that this marriage was still in effect?

Month

Day

Year

Answer Item 22 only if either of you had an earlier ceremonial or common-law marriage that ended after you began living together.

22 a When and how did you first learn that this marriage had ended?
b When and how did the person you were living with first learn that this marriage had ended?
c After both of you learned that the earlier marriage had ended, did you say anything to

each other about your relationship changing? If “Yes,” what did you say to each other?

Month

Year

Month

Year

R Yes

R No

23 (This space may be used for explaining any answers to the questions. If you need more space, attach a separate sheet.)
Remarks

24 Certification: Failure to report or the making of a false or fraudulent report may result in criminal prosecution or civil penalties,

or both. I understand that civil and criminal penalties may be imposed on me for false or fraudulent statements, or for withholding
information to cause or prevent payment of benefits by the RRB. I affirm that to the best of my knowledge, the information I have
given is true, complete, and correct.

Signature of person making statement

Date (Month, Day, Year)

Signature (First Name, Middle Initial, Last Name)
Daytime Telephone Number

(

)

Mailing Address (Number and Street, Apt. No., P.O. Box, etc.)
City and State

ZIP Code

County (if any)

25 If the certification is signed by mark (X) in Item 24, two witnesses who know the person signing must sign below, giving their full
addresses and daytime telephone numbers.
a. Signature of Witness

b. Signature of Witness

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

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

Daytime Telephone Number

Daytime Telephone Number

(

(

)

Form G-124 (xx-xx)

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