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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.