G-124A (Proposed) Statement Regarding Marriage

PROPOSED

United States of America
Railroad Retirement Board

Certification of
Marriage Information

Form Approved
OMB No. 3220-0021

RRB Claim No.:
E mployee'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 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 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 11, Remarks, for this purpose.
1 Name of Applicant
I understand that this statement will be considered in connection with an application by the person named in Item 1,
for payment of benefits, under the provisions of the Railroad Retirement Act, as amended, based on the service
and compensation of the employee named above.
2 Your Full Name
3 a What is your relationship to the EMPLOYEE (mother, child, cousin, etc.)?—If not related, enter “None.”
b What is your relationship to the APPLICANT (mother, child, cousin, etc.)?—If not related, enter “None.”
4 a How long have you known the EMPLOYEE?
b How long have you known the APPLICANT?
5 a How often and on what occasions did you meet the EMPLOYEE?

b How often and on what occasions did you meet the APPLICANT?

6 Did (do) you consider the employee and the applicant husband and wife? Give facts and
explain fully the reasons for your belief.

7 Did you hear them refer to each other as husband and wife? If “Yes,” when and where?

Continued

o

Yes

o

No

o

Yes

o

No

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

Answer Items 8, 9, and 10 to the best of your knowledge and belief.
8 In your opinion, did (do) they maintain a home and live together as husband and wife?

❏

If “Yes,” when and where?

City or Town

State

❏

Yes

No

Dates
To

From

9 To your knowledge, did they live together continuously? If “No,” explain.

❏

Yes

❏

No

10 To your knowledge, has either the employee or applicant entered into any other marriage?

❏

Yes

❏

No

If “Yes,” give the following information regarding all such marriages.
State whether employee
or applicant

To Whom Married

Date and Place
of Marriage

How Marriage Ended

Date and Place
Marriage Ended

11 Remarks: Use this space 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. If you need more space, attach a separate sheet.

12 Certification: Failure to report or the making of a false or fraudulent report can 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.
Date (Month, Day, Year)
Signature of person making statement

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)

13 If the certification is signed by mark “(X)” in Item 12, 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-124a (xx-xx)

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