G-238 (Proposed) Statement of Residence

PROPOSED

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0021

RRB Claim No.:

Statement
of Residence

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

Paperwork Reduction Act and P rivacy 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 3 to 5
minutes per response to complete, including the time for
1 Your Full Name

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.

2 Name of person whose residence(s) you are certifying
3 I certify that the person named above resided in the following places during the periods shown.
Note: Where residence in a period is unknown, show the period and enter “Unknown” under “City or Town.”
City or Town

County

State

From
Month

To
Year

Month

Year

4 Explain how you know where the person lived.

5 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) (Write in Ink)
Daytime Telephone Number

(

)

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

City and State

ZIP Code

County (if any)

6 If the certification is signed by mark (X) in Item 5, 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-238 (xx-xx) Destroy prior editions