G-238A (Proposed) Statement Regarding Divorce or Annulment

PROPOSED

United States of America
Railroad Retirement Board

Statement Regarding
Divorce or Annulment

Form Approved
OMB No. 3220-0021

RRB Claim No.:
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 10 minutes per
response to complete, including the time for reviewing the

Part 1

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.

To be completed by Applicant

To: (Name and Address—Custodian of Records)

From: (Name and Address—Applicant)

To support my application for benefits under the Railroad Retirement Act, I must submit a statement showing whether or not a
divorce was obtained. Please check the divorce and annulment records, complete and sign this form, and return it to me.
Period(s) for which records
Name of parties to divorce or annulment action
are to be checked
(include other names by which these parties may have been known)
From
To

and
and
and
and
Signature

Part 2

1

Date

To be completed by Custodian of Records

Were the divorce and annulment records checked for the entire period(s) shown above?

o

Yes

o

No

o

Yes

o

No

If “No,” explain:

2

Was a record of a divorce or annulment action found?
If “Yes,” show the date and type of decree issued:
Date:

3

Type of Decree:

Remarks

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.
Signature and Title

Date

Form G-238a (xx-xx) Destroy prior editions