Information Collection

Statement Regarding Contributions and Support of Children

IC 34014 under ICR 201708-3220-003 · OMB 3220-0195.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0195 can be found here:

Documents and Forms

Document Name Document Type
Form G-139 Statement Regarding Contributions and Support of Children Form
G-139 Statement Regarding Contributions and Support of Childre Form G-139 (04-17).pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Statement Regarding Contributions and Support of Children	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 222.50 20 CFR 222.53 20 CFR 222.55 20 CFR 222.51 20 CFR 222.57 20 CFR 222.56

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	G-139	Statement Regarding Contributions and Support of Children	Form G-139 (04-17).pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: RRB-22, Railroad Retirement, Survivor and Pensioner Benefit System	FR Citation: 79 FR 58874

Number of Respondents: 500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	500	500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.