Form G-204 (xx-xx) - Pr G-204 (xx-xx) - Pr Verification of Workers Compensation/Public Disability

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

FORM APPROVED
O.M.B. NO. 3220-0002

PROPOSED
VERIFICATION OF WORKER’S COMPENSATION/PUBLIC
DISABILITY BENEFIT INFORMATION

PAPERWORK REDUCTION AND PRIVACY ACT NOTICE
The information asked for in this form is needed to verify that the individual named below has received or will receive either worker’s compensation or
public disability benefits. The Railroad Retirement Board (RRB) needs this information to determine the effect these benefits will have on this person’s
retirement annuity. The RRB’s authority for requesting this information is section 7(b)(6) of the Railroad Retirement Act.
We estimate this form takes an average of 15 minutes per response, 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 aspects of this form, including suggestions for
reducing the completion time, to Associate Chief Information Officer of Policy and Compliance, Railroad Retirement Board, 844 Rush St., Chicago, IL
60611-1275.

TO

SIGNATURE OF RAILROAD RETIREMENT BOARD OFFICIAL

O

TITLE

DATE

COMPUTER MATCHING AND PRIVACY PROTECTION ACT NOTICE
The Computer Matching and Privacy Protection Act of 1988 requires the RRB to advise you that information you have provided may be used, without your
consent, in automated matching programs. These matching programs are a computer comparison of RRB records with records kept by other Federal, state
or local governmental agencies. Information from these matching programs can be used to establish or verify a person’s eligibility for federally funded or
administered benefit programs and for repayment of payments or delinquent debts under these programs.

1

RAILROAD RETIREMENT CLAIM NUMBER

2

SOCIAL SECURITY NUMBER

3

NAME

4

ADDRESS

CLAIM
NUMBER

5

WORKER’S COMPENSATION/PUBLIC
DISABILITY BENEFIT CLAIM NUMBER

AUTHORIZATION
(To be completed
by individual named
in Item 3 if such
authorization is
required)

6

I request and authorize release of any information concerning
my claim for worker’s compensation or other public disability
benefits to the Railroad Retirement Board.

EMPLOYEE
IDENTIFICATION
(To be completed
by the Railroad
Retirement Board)

SIGNATURE OF CLAIMANT

Items 7 through 22 are to be completed by the provider of the worker’s compensation or public disability payments.
Use Item 21, Remarks, to complete or continue any additional information.
STATUS
OF CLAIM

7

Enter an “X” in the box that shows the
status of the above-mentioned person’s
claim for worker’s compensation or
public disability benefits.

R
R
R
R

CLAIM APPROVED (Include any
previous periodic or
lump-sum payments)
NO RECORD OF CLAIM
CLAIM DENIED – NO APPEAL
CLAIM DENIED – APPEAL PENDING

}

Go to Item 8

Go to Item 22

FORM G-204 (xx-xx)

PERIODIC
PAYMENTS

8

If no periodic payments are involved go to Item 12.
Enter the following information about the periodic payments this individual has received or will receive. List each
change of amount on a separate line.
DATE
BEGAN

9

10

LUMP-SUM
PAYMENTS

DATE
ENDED

ATTORNEY FEES AND
OTHER EXPENSES
INCLUDED IN
WEEKLY AMOUNT

WEEKLY
AMOUNT

TYPE OF PAYMENTS
TEMPORARY
PARTIAL

PERMANENT

TOTAL

PARTIAL

Enter an “X” in the appropriate box:
The individual named in Item 3 is still
receiving periodic payments.

R
R

YES

Go to Item 16

NO

Go to Item 10

Enter an “X” in the box that explains why
the most recent periodic payments have
stopped.

R
R

INDIVIDUAL RETURNED TO WORK

R
R

AWARD UNDER APPEAL

R
R

LUMP-SUM AWARD PENDING

INDIVIDUAL WAS PAID THE LAW OR
PLAN’S MAXIMUM AMOUNT

PERMANENT RATING PAID/PENDING

OTHER REASON

12

Enter the following information about the lump-sum payment(s) this individual has received or will receive.

13

FORM G-204 (xx-xx)

RATE(S) PER
WEEK

Enter an “X” in the appropriate box(es):
Enter the type and amount of the fees or expenses
that were included in the gross amount(s).

Page 2

NUMBER OF
WEEKS

}

Go to
Item 11

Explain in Item 21,
then go to Item 16

Enter the date a decision is expected,
then go to Item 16.

GROSS
AMOUNT(S)

}

Go to
Item 16

Go to
Item 12

11

DATE OF
SETTLEMENT(S)

TOTAL

BEGINNING
DATE

R

PRESENT AND PAST
MEDICAL EXPENSES

$ ___________________

R

FUTURE MEDICAL
EXPENSES

$ ___________________

R

ATTORNEY FEES

$ ___________________

R

OTHER RELATED
EXPENSES
(Explain in Item 21.)

$ ___________________

14

BENEFIT
REDUCTION

PUBLIC
DISABILITY
BENEFITS

Enter an “X” in the appropriate box:
A lump-sum award for this individual is pending.

R YES
R NO

15

Enter the date a decision is expected regarding
the lump-sum payment.

16

Enter an “X” in the appropriate box:
The benefits this individual is receiving or did receive
are being reduced because (s)he is receiving
social security disability benefits.

Go to Item 15
Go to Item 16

R YES
R NO

Complete Item 17 only if this individual is receiving payments that are not worker’s compensation.
If the benefits are worker‘s compensation, go to Item 22.

17

18

Enter an “X” in the appropriate box:
This individual is a federal, state, or
local government employee.

R YES
R NO

Go to Item 18

Enter an “X” in the appropriate box:
Social security taxes (F.I.C.A.) were
paid on this individual’s earnings.

R YES
R NO

Go to Item 19

Go to Item 22

Go to Item 22

19

Enter the number of years this individual’s
employment was covered by social security.

20

Enter the total number of years (F.I.C.A.
and non-F.I.C.A.) used to establish this
individual’s benefit.

REMARKS

21

Use to continue any entries for previous Items 7-20

CERTIFICATION

22

I know that if I make a false or fraudulent statement, I am committing a crime which is punishable under law. I certify
that the information I gave the Railroad Retirement Board on this form is true to the best of my knowledge.
BENEFIT PROVIDER AGENCY REPRESENTATIVE SIGNATURE

YOUR DAYTIME TELEPHONE NUMBER
(Include Area Code)

YOUR JOB TITLE

DATE

Page 3

FORM G-204 (xx-xx)

RETURN THIS FORM, WHEN COMPLETED, TO:

May be used for window
envelope if folded properly.

US Railroad Retirement Board
844 N Rush Street
Chicago IL 60611-1275

IF YOU HAVE ANY QUESTIONS REGARDING THIS FORM, YOU MAY
CALL OR WRITE:

U.S. RAILROAD RETIREMENT BOARD

FORM G-204 (xx-xx)

Page 4