Information Collection

Statement Regarding Contributions and Support

IC 33902 under ICR 202011-3220-003 · OMB 3220-0099.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0099 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form G-134 (Proposed) Statement Regarding Contributions and Support	Form
G-134 Statement Regarding Contributions and Support Form G-134 (05-17).pdf	Form
G-134 Statement Regarding Contributions and Support Form G-134 (05-17).pdf	Form
G-134 (Proposed) Statement Regarding Contributions and Support Form G-134 (xx-xx) - PROPOSED.pdf	Form
G-134 (Proposed) Statement Regarding Contributions and Support Form G-134 (xx-xx) - PROPOSED.pdf	Form
Form RL-57A-F (10-82).pdf Letter Requesting Applicant to Furnish Evidence	IC Document
Form RL-57A-F (10-82).pdf Letter Requesting Applicant to Furnish Evidence	IC Document
Form G-242 (01-07).pdf Notice of Information Needed in Claim under the RRA	IC Document
Form G-242 (01-07).pdf Notice of Information Needed in Claim under the RRA	IC Document
SSA-760-F4.pdf Support of Certificate	IC Document
SSA-760-F4.pdf Support of Certificate	IC Document

IC Title:

Statement Regarding Contributions and Support

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 216.81 20 CFR 222.41(4)

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-134	Statement Regarding Contributions and Support	Form G-134 (05-17).pdf		No		Paper Only
Form	G-134 (Proposed)	Statement Regarding Contributions and Support	Form G-134 (xx-xx) - PROPOSED.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: 100

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	100	100
Annual IC Time Burden (Hours)	259	259
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Letter Requesting Applicant to Furnish Evidence	Form RL-57A-F (10-82).pdf	09/14/2017
Notice of Information Needed in Claim under the RRA	Form G-242 (01-07).pdf	09/14/2017
Support of Certificate	SSA-760-F4.pdf	11/23/2020

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