Form G-93 (11-12) G-93 (11-12) Statement of Claimant or Other Person

CURRENT

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

FORM APPROVED
OMB No. 3220-0183

STATEMENT OF CLAIMANT OR OTHER PERSON
NAME OF RAILROAD EMPLOYEE

SOCIAL SECURITY NUMBER OF RAILROAD EMPLOYEE

NAME OF CLAIMANT (If other than railroad employee)

RR RETIREMENT ANNUITY CLAIM NUMBER (If different from
SS Number)

RELATIONSHIP TO CLAIMANT OF PERSON MAKING STATEMENT

NAME OF PERSON MAKING STATEMENT (If other than claimant)

PLEASE READ THE "IMPORTANT NOTICES" ON THE NEXT PAGE
Understanding that this statement is for the use of the Railroad Retirement Board (RRB), I hereby certify that:

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) If additional space is needed, mark an "X" and continue on the next page.

CERTIFICATION
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 OF PERSON MAKING STATEMENT
(First Name, Middle Initial, Last Name) (Write in Ink)

DATE (Month, Day, Year)

SIGN
HERE

TELEPHONE NUMBER (Include Area Code)

MAILING ADDRESS (Number and Street, Apt., No., P.O. Box, Rural Route)

CITY, STATE, AND ZIP CODE

If this statement has been signed by mark "X," two witnesses who know the person signing must sign below, giving their
full addresses.
1. SIGNATURE OF WITNESS

2. SIGNATURE OF WITNESS

ADDRESS (Number and Street, City, State, and ZIP Code)

ADDRESS (Number and Street, City, State, and ZIP Code)

(Continued)

RRB FORM G-93 (11-12)

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) Continuation of Statement:
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IMPORTANT NOTICES
Paperwork Reduction Act/Privacy Act Notice
The Railroad Retirement Board (RRB) is authorized to collect the information requested on this form under Section 7(b)(6) of the
Railroad Retirement Act (RRA) and Section 5(b) of the Railroad Unemployment Insurance Act (RUIA). The information will be used
to determine entitlement to benefits under these Acts. You are not required to provide this information, however, your failure to do so may
result in the loss of benefits for which an application has been filed.
The information you provide on this form may be disclosed without your approval to any individual or institution you identified on this
form. Such information may also be disclosed without your approval to the Government Accountability Office for audits, to the
Justice Department for collecting overpayments owed to the RRB or the Social Security Administration or for use in criminal and
civil proceedings relating to this claim for benefits, to other law enforcement agencies engaged in functions related to the RRA or
RUIA, and in administrative hearings or court proceedings relating to a claim for benefits under the Acts.
A complete listing of persons, organizations, and agencies to which the information you give us may be released is available at any
office of the RRB, if you wish to see it.
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We estimate this form takes an average of 15 minutes per response 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 Chief of Information Resources
Management, Railroad Retirement Board, 844 N. Rush Street, Chicago, IL 60611-2092.
RRB FORM G-93 (11-12)