G-346sum (03-18) Employee's Certification Summary

CURRENT (COMPLETED)

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0140

EMPLOYEE’S CERTIFICATION
INSTRUCTIONS
The following information was either supplied by or verified by you. Review the information for
accuracy. If there are any errors, notify the Railroad Retirement Board (RRB) immediately and no later
than 10 days from the date you receive this summary.
EMPLOYEE INFORMATION
Railroad Retirement Claim Number

A 123-45-6789

Employee’s Social Security Number

123-45-6789

Employee’s Name

John Doe

YOUR MARRIAGE INFORMATION
I am currently married to Justine Doe.
I was married before my current marriage.
The following is a list of my marriages before my current marriage.
Date Began
01/28/1993

Name
Jane Doe

How Ended
Annulment

Date Ended
02/14/1993

RELINQUISHMENT OF RIGHTS BY DISABILITY ANNUITANTS AND CERTIFICATION
I recognize that my spouse may not begin to receive an annuity while I hold rights to return to work for a
railroad employer. I authorize the RRB to relinquish any rights I may have to return to work for a
railroad employer. Based on this authorization, my rights will be relinquished if my spouse becomes
entitled to a spouse’s annuity. I understand this authorization remains in effect unless I revoke it in
writing.
Certification
This information is certified by you to be true and correct to the best of your knowledge. You have
been informed and you acknowledge that making a false or fraudulent statement or withholding
information, in order to receive benefits from the RRB, is a crime under Federal law, which may be
punishable by fines, imprisonment, or both.
Paperwork Reduction Act and Privacy Act Notices
The Railroad Retirement Board is authorized to collect the information on this form by Section 7(b)(6) of
the Railroad Retirement Act. This information is needed to determine your spouse’s or former spouse’s
entitlement to benefits under the Railroad Retirement Act. You are not required to provide the
information requested by this form, however, your failure to do so may result in your spouse or former
spouse not receiving these benefits.
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RRB Form G-346sum (03-18)

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0140

We estimate this form takes an average of 5 minutes 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 the Associate
Chief Information Officer for Policy and Compliance, Railroad Retirement Board, 844 North Rush Street,
Chicago, IL 60611-1275.

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RRB Form G-346sum (03-18)