Form G-315A Statement of School Official

Form Approved
OMB No. 3220-0123

CURRENT

United States of America
Railroad Retirement Board

Statement of School Official
Paperwork Reduction Act and Privacy Act Notices
The Railroad Retirement Board's (RRB) authority for requesting this information is contained in Section
7(b)(6) of the Railroad Retirement Act (45 U.S.C. 231f(b)(6)). While you are not required to respond, your
cooperation in promptly completing and returning this form will be appreciated. Failure to do so may result
in nonpayment of RRB benefits to the student.
We estimate this form takes an average of 3 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 Associate
Chief Information Officer for Policy and Compliance, Railroad Retirement Board, 844 North Rush St.,
Chicago IL 60611-1275.

Section A

Full-Time Attendance Information Provided By The Student

1.

Student's Name

3.

Type of school the student was
attending, is currently attending, or will
resume attending within four months

4.

Name of the school

2.

Student's Social
Security Number

Elementary School
High School Level (Including Technical and Vocational)
Home School

5. Student dates of full-time attendance at the school named in Item 4

Began
Month and Year

Ended
Month and Year

6. Number of hours per week the student was, is, or will be scheduled
to attend the school named in Item 4

Scheduled Hours Per Week

7. Expected month and year of graduation date, if the student was, is,
or will be studying at the high school level

Month and Year

Certification of School Official
The School Official is to enter an "X" in the appropriate boxes.
ink any requested information.
8. Is the information provided by the student in Section A, in
agreement with your records?
9. Was the student ever in attendance at your school on a full-time
basis?

Section B

10. Enter the student’s last period of full-time attendance at your
school.

Type or complete legibly in
Yes - Go to Item 13
No - Go to Item 9
Yes - Go to Item 10
No - Go to Item 13

Began
Month and Year

Ended
Month and Year

Yes
11. Is, or was, the student scheduled to attend your school for 20 or
more hours per week?
No
Month and Year
12. If the Railroad Retirement Board office entered a graduation month and year in
Section A, Item 7, that does not agree with your records, enter the correct month
and year the student is expected to graduate from your school.
13. Knowing that anyone making a false statement or representation of a material fact for use in
determining a right to payment under the Railroad Retirement Act commits a crime punishable under
Federal Law, I certify that according to this school’s records, the information given above is true.
Print Name of School Official
Signature of School Official
Title

Telephone Number

(

Date

)

RRB Form G-315A (10-17) Destroy Prior Editions