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United States Of America
Railroad Retirement Board
FORM APPROVED
OMB NO. 3220-0083
STATEMENT REGARDING FAMILY AND EARNINGS
FOR SPECIAL GUARANTY COMPUTATION
SECTION 1
General Instructions
Before you complete this statement, be sure to read the booklet G-179, Special Guaranty in Employee and Spouse Annuities,
which explains the information you will need to answer many of the questions in this statement.
Please read “Important Notices” on the last page of this statement.
Type or print all answers legibly in ink. If you need more space than is provided to answer a question, use Section 8 for this
purpose. If you do not know the answer, print “unknown” in the space provided for the answer.
When entering dates, always use numbers. Also, be sure there is one number in each box. For example, you would enter
January 2, 2018, as:
MONTH
DAY
YEAR
0 1 0 2 1 8
Some items in this statement will not apply to you so you will not need to answer them. Based on your answer to a question,
you may be told to skip to another item number or even another section. Follow the instructions that tell you to “Go to”
another item. These are designed to save you time and help you move through the statement quickly, filling in only necessary
information. If no “Go to” instructions are given, answer the next item in order. Do not skip any item unless directed
to do so.
If you are completing this statement on behalf of someone else, you must answer each question as it applies to that person.
SECTION 2
Identifying Information
Check the information entered by the Railroad Retirement Board (RRB) for Items 1 and 2 for accuracy.
If the information is correct, go to Section 3.
If the information is not correct, cross out the incorrect information and enter the correct information above it.
If the information is missing, fill it in.
Employee
Identification
1
Railroad Employee’s Name
2
Railroad Employee’s RRB Claim Number
(Employee’s Social Security Number)
SECTION 3
A
Information About The Spouse
Complete this section only if you are filing this statement as the spouse and you have not filed Form AA-3, Application for
Spouse/Divorced Spouse Annuity. Otherwise, go to Section 4.
Spouse
Identification
3
YOUR NAME
4
a STREET ADDRESS
b CITY AND STATE
c
ZIP CODE
d COUNTY
5
DAYTIME TELEPHONE NUMBER
AREA CODE
TELEPHONE NUMBER
Form G-319 (03-18) Destroy Prior Editions
Social
Security
Birth Date
6
Enter an ”X” in the appropriate box:
q Yes
q No
My name appears on my social security card exactly
as it does in Item 3.
7
Enter your name as it appears
on your social security card.
8
Enter your social security number.
9
Enter your date of birth.
Name at
Birth
10 Enter your name at birth if
Current
Marriage
11 Enter the date of your current marriage to the railroad employee.
Previous
Marriage
12 Enter an ”X” in the appropriate box:
Go to Item 8
Go to Item 7
MONTH
DAY
YEAR
MONTH
DAY
YEAR
different from Item 3.
q Yes
q No
I was married to another person before my marriage to the
railroad employee.
Go to Item 13
Go to Section 4
13 Enter the following information regarding each of your previous marriages. If more space is needed, continue in Section 8.
a
Full Name of Person You Were Married To
Social Security Number of Person You Were Married To
Date Married
(Month/Day/Year)
M
b
D
City and State
Married
Y
How Marriage
Ended
(Check One)
q Death
q Divorce
q Annulment
Date Marriage Ended
(Month/Day/Year)
M
D
City and State
Marriage Ended
Y
Full Name of Person You Were Married To
Social Security Number of Person You Were Married To
Date Married
(Month/Day/Year)
M
SECTION 4
Minor
Children
D
City and State
Married
Y
How Marriage
Ended
(Check One)
q Death
q Divorce
q Annulment
Date Marriage Ended
(Month/Day/Year)
M
D
City and State
Marriage Ended
Y
Information About Children
14 Enter an ”X” in the appropriate box:
q Yes
q No
I have an unmarried child under age 18 as defined in the
G-179 booklet. If I am filing as a spouse, the child is in my care.
Go to Item 15
Go to Item 16
15 Enter the requested information for every minor child for whom you are filing this statement. Enter the youngest minor child
in a, the second youngest in b, and so on. If the child does not have a social security number, enter “To Be Submitted.”
Note: If Stepchild or Grandchild is checked below, you must also complete Form G-139, Statement
Regarding Contributions and Support of Children.
Minor Child’s Full Name and
Social Security Number
Relationship To You
(Check One For
Each Child)
a
NATURAL
ADOPTED
STEPCHILD
GRANDCHILD
OTHER
q
q
q
q
q
b
NATURAL
ADOPTED
STEPCHILD
GRANDCHILD
OTHER
q
q
q
q
q
c
NATURAL
ADOPTED
STEPCHILD
GRANDCHILD
OTHER
q
q
q
q
q
Form G-319 (03-18)
Page 2
Enter An “X” In The
Appropriate Box:
The Minor Child Is
Living With Me
Date of Birth
MONTH
DAY
YEAR
q
q
Yes
No
MONTH
DAY
YEAR
q
q
Yes
No
MONTH
DAY
YEAR
q
q
Yes
No
Disabled
Children
16 Enter an ”X” in the appropriate box:
q Yes
I have an unmarried child age 18 or older who became disabled for all
employment before age 22 as defined in the G-179 booklet. If I am filing
as a spouse, the child is in my care.
q No
Go to Note and
Item 17
Go to Item 18
Note: If answered “Yes,” the employee or spouse is also to complete Form AA-19a,
Application for Determination of Child’s Disability, for the child.
17 Enter the requested information for every disabled child for whom you are filing this statement. Enter the
youngest disabled child in a, the second youngest in b, and so on. If the child does not have a social security
number, enter “To Be Submitted.”
Note: If Stepchild or Grandchild is checked below, you must also complete Form G-139,
Statement Regarding Contributions and Support of Children.
Disabled Child’s Full Name and
Social Security Number
Student
Children
Relationship To You
(Check One For
Each Child)
a
NATURAL
ADOPTED
STEPCHILD
GRANDCHILD
OTHER
q
q
q
q
q
b
NATURAL
ADOPTED
STEPCHILD
GRANDCHILD
OTHER
q
q
q
q
q
c
NATURAL
ADOPTED
STEPCHILD
GRANDCHILD
OTHER
q
q
q
q
q
Enter An “X” In The
Appropriate Box:
The Disabled Child Is
Living With Me
Date of Birth
MONTH
DAY
YEAR
q
q
Yes
No
MONTH
DAY
YEAR
q
q
Yes
No
MONTH
DAY
YEAR
q
q
Yes
No
18 Enter an ”X” in the appropriate box:
q Yes
I have an unmarried child age 18 –19 who is attending an
elementary or secondary school full time as defined in the
G-179 booklet.
q No
Go to Note and
Item 19
Go to Item 20
Note: If answered “Yes,” the employee must also complete Form G-320, Student Questionnaire
for Special Guaranty Computation.
19 Enter the requested information for every student for whom you are filing this statement. Enter the youngest
student in a, the second youngest in b, and so on. If the child does not have a social security number, enter
“To Be Submitted.”
Note: If Stepchild or Grandchild is checked below, you must also complete Form G-139, Statement
Regarding Contributions and Support of Children.
Student’s Full Name and
Social Security Number
Relationship To You
(Check One For
Each Child)
a
NATURAL
ADOPTED
STEPCHILD
GRANDCHILD
OTHER
q
q
q
q
q
b
NATURAL
ADOPTED
STEPCHILD
GRANDCHILD
OTHER
q
q
q
q
q
c
NATURAL
ADOPTED
STEPCHILD
GRANDCHILD
OTHER
q
q
q
q
q
Page 3
Enter An “X” In The
Appropriate Box:
The Student Is
Living With Me
Date of Birth
MONTH
DAY
YEAR
q
q
Yes
No
MONTH
DAY
YEAR
q
q
Yes
No
MONTH
DAY
YEAR
q
q
Yes
No
Form G-319 (03-18)
Children
Not Living
With You
20
Enter the requested information for each child in Items 15, 17, and 19 who is not living with you. Enter the youngest
child in a, the second youngest in b, and so on. Otherwise, go to Item 21.
Full Name
Of Child
Person With Whom Child Now Lives
Child’s
Address
Relationship
To Child
Name
a
b
c
Married
Children
21 Enter an ”X” in the appropriate box:
One or more of the minor children in Item 15 or a
student in Item 19 has been married in the past.
q Yes
Go to Item 22
q No
Go to Section 5
22 Enter the requested information for every minor child or student who has ever been married. Enter the youngest
child in a.
Child’s Married Name
Date Marriage Began
MONTH
DAY
YEAR
a
Date Marriage Ended
MONTH
DAY
b
SECTION 5
Information About Other Government Benefits
When answering Items 23 and 24, consider only yourself, the minor children listed in Item 15, and the students listed in Item 19.
Social
Security
Benefits
23 Enter an ”X” in the appropriate box:
An application has been filed or will be filed for
monthly social security benefits for me,
a minor child, a student, or a disabled child.
q Yes
Go to Item 24
q No
Go to Item 25
24 Enter the requested information for the family members for whom an application has been filed or will be filed for
monthly social security benefits. Use as many lines as needed beginning with a.
Name Of
Family Member
Person Whose Record
Was Filed On Or
Will Be Filed On
a
b
c
Form G-319 (03-18)
Page 4
Social Security Number
That Was Filed On Or
Will Be Filed On
YEAR
When answering Items 25 through 27, consider everyone in the family group.
RRB
Benefits
25
Enter an ”X” in the appropriate box:
An application has been filed, or will be filed by me or
by a member of the family group, for monthly railroad
retirement benefits on another claim number.
26
Enter the name of the person on whose record
the application has been filed or will be filed.
27
Enter the other person’s railroad retirement claim number.
(Include the letter prefix)
q Yes
q No
Prefix RRB Claim No
Go to Item 26
Go to Item 28
If only 6 numbers, enter here
Answer Items 28 through 30 only if you are the spouse and you have not filed Form AA-3, Application for Spouse/Divorced Spouse
Annuity. Otherwise, go to Section 6.
Public
Service
Pension
28
29
Enter an ”X” in the appropriate box:
I am receiving, or expect to receive, a pension or I have
received, or expect to receive, a lump-sum payment instead
of a pension, based on my own earnings, from an agency of
the Federal, state, or local government. (Answer “No” if your
only government pension payments are social security,
railroad retirement, veterans affairs, worker’s compensation,
or black lung benefits. Also answer “No” if you received a
lump-sum payment that was just your contributions to the
pension fund plus interest.)
Enter an ”X” in the appropriate box:
I am/was an employee of the Federal Government.
q Yes
Go to Item 29
q No
Go to Section 6
q Yes
Go to Note and
Section 6
Go to Section 6
q No
Note: If answered “Yes,” complete and return to the RRB, Form G-208, Public Service Pension
Questionnaire, and verification of your pension.
30
Enter an "X" in the appropriate box:
In the last 60 months of employment, I was employed by a state or
local government or the military service, and social security (FICA)
taxes were being deducted from my public service earnings.
q Yes
q No
Go to Section 6
Go to Note and
Section 6
Note: If answered “No,” complete and return to the RRB, Form G-208, Public Service Pension
Questionnaire, and verification of your pension.
SECTION 6
Information About Work and Earnings
Please read the G-179 booklet to find out how work and earnings can affect your annuity increase. Also, refer to Form G-77a,
How Work Affects Your Railroad Retirement Benefits, when answering Items 31 through 37.
When answering Items 31 though 37, consider only yourself (if you are not a disability annuitant under age 65), the minor
children listed in Item 15, and the students listed in Item 19.
Answer Item 31 only if the Special Guaranty increase can begin before January 1 of this year. Otherwise, go to Item 33.
Earnings
Last Year
________
31
Enter an ”X” in the appropriate box:
One or more family members, who are
subject to the annual earnings exempt
amount, had total earnings for all
employment last year that exceeded their
annual earnings exempt amount.
q Yes
q No
Page 5
Go to Item 32
Go to Item 33
Form G-319 (03-18)
Earnings
Last Year
(Cont.)
32 Enter the following information for the family member(s) whose total earnings for last year were more than their
annual earnings exempt amount shown on Form G-77a. Use as many lines as are needed beginning with a.
Total Earnings
For Last Year
(Show Dollars
Only)
Name of
Family Member
$
a
c
Earnings
This Year
________
q YES
$
b
Enter An ”X” In The
Appropriate Box:
The Family Member
Earned More Than The
Monthly Earnings Exempt
Amount In Employment
For Hire Or Performed
Substantial Services In
Self-Employment
In Every Month Last Year
q YES
$
q YES
q NO
q NO
q NO
33 Enter an ”X” in the appropriate box:
One or more family members, who are subject to the annual
earnings exempt amount, expect to have total earnings for
all employment this year that will exceed their annual
earnings exempt amount.
Enter an ”X” Next To Each Month Last
Year In Which The Family Member Did
Not Earn More Than the Monthly
Earnings Exempt Amount Or Perform
Substantial Services In Self-Employment
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
q Yes
Go to Item 34
q No
Go to Item 35
34 Enter the following information for the family member(s) whose total earnings for this year are expected to be
more than their annual earnings exempt amount shown on Form G-77a. Use as many lines as are needed
beginning with a.
Total Expected
Earnings For
This Year (Show
Dollars Only)
Name of
Family Member
a
Form G-319 (03-18)
$
Enter An ”X” In The
Appropriate Box:
The Family Member
Expects To Earn More Than
The Monthly Earnings
Exempt Amount In
Employment For Hire Or To
Perform Substantial
Services In SelfEmployment In Every Month
This Year
q YES
Page 6
q NO
Enter An ”X” Next To Each Month This
Year In Which The Family Member Did
Not Or Does Not Expect to Earn More
Than The Monthly Earnings Exempt
Amount Or Perform Substantial Services
In Self-Employment
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
Earnings
This Year
(Cont.)
34
b
c
Earnings
Next Year
$
q YES
$
q YES
35 Enter an ”X” in the appropriate box:
I am returning this statement in September,
October, November, or December.
________
q NO
q NO
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
q Yes
Go to Item 36
q No
Go to Section 7
q Yes
q No
Go to Item 37
36 Enter an ”X” in the appropriate box:
One or more family members, who are subject to the annual
earnings exempt amount, expect to have total earnings for
all employment that will exceed their annual earnings
exempt amount for next year.
Go to Section 7
37 Enter the following information for the family member(s) whose total earnings for next year are expected to be
more than their annual earnings exempt amount. Use as many lines as are needed, beginning with a.
Earnings Expected For Next Year
(Show Dollars Only)
Name of Family Member
a
$
b
$
c
$
SECTION 7
Information That Affects Entitlement
Complete this section only if you have not previously reported this information to the RRB. Otherwise, go to Section 8.
Criminal
Offense
38
Enter an ”X” in the appropriate box:
Within the past 12 months, I have been, or a family
member has been, imprisoned or given a sentence of
confinement due to a conviction for a criminal offense.
39
Enter the name of the family member
described in Item 38.
40
Enter the date of the conviction.
41
Enter the date of the sentence of confinement.
42
q Yes
Go to Item 39
q No
Go to Section 8
MONTH
DAY
YEAR
MONTH
DAY
YEAR
MONTH
DAY
YEAR
Enter the date that confinement began.
Page 7
Form G-319 (03-18)
Criminal
Offense
(Cont.)
43 Enter an ”X” in the appropriate box:
The confinement has ended.
SECTION 8
Go to Item 44
q No
Go to Section 8
MONTH
44 Enter the date the confinement ended.
Remarks
q Yes
DAY
YEAR
Remarks
45 This section is to be used for the continuation of answers to other Items. Be sure to include the item number at the
beginning of the answer you wish to continue. You may use this section to enter any additional information that you
feel may be important to include.
Form G-319 (03-18)
Page 8
SECTION 9
Certification 46
Certification
Enter an ”X” in the appropriate box:
I am:
the employee named in Item 1
Go to Item 47
the spouse named in Item 3
q Yes
q Yes
Other - explain relationship below (i.e., Attorney)
q Yes
Read the Note,
then go to Item 47
Explanation: ___________________________________________
Go to Item 47
Note: If you are completing this statement on behalf of the employee or spouse, you must
answer each question as it applies to that person. You must also sign this statement in Item 47.
47
I know that if I make a false or fraudulent statement in order to receive benefits from the Railroad Retirement Board
(RRB), I am committing a crime which is punishable under Federal law. I have received booklet G-179, Special
Guaranty in Employee and Spouse Annuities. I also understand that I am responsible for reporting any events
that would affect my benefits, as explained in that booklet.
I certify that the information I gave to the RRB on this statement is true to the best of my knowledge.
I agree to immediately notify the RRB:
l
l
l
l
l
If my marriage ends by death or divorce.
If a minor or disabled child included in the computation of the annuity leaves the custody of the spouse,
marries, dies, or enters military service.
If a family member files an application for social security benefits on any person’s earnings record.
If the spouse begins to receive a public service pension or there is a change in the amount of the public
service pension.
If I or a family member is confined to a jail, prison, penal institution, or correctional facility due to a conviction
for a criminal offense.
Also, I agree to immediately notify the RRB if I or a family member, included in the annuity computation, earns more
than the annual earnings exempt amount. Failure to report these earnings on a timely basis may result in penalty
deductions from the Special Guaranty benefits.
SIGNATURE
(First Name, Middle
Initial, Last Name)
MONTH
DAY
YEAR
DATE
48
If this certificate is signed by mark (“X”) in Item 47, two witnesses who know the person signing must sign below,
giving their full addresses and daytime telephone numbers.
a. Signature of Witness
Address (Number and Street)
City, State, ZIP Code
Daytime Telephone Number
Area Code
Telephone Number
Area Code
Telephone Number
b. Signature of Witness
Address (Number and Street)
City, State, ZIP Code
Daytime Telephone Number
Page 9
Form G-319 (03-18)
SECTION 10
How To Return This Statement
Before you return this statement, check to make sure that:
Every question that applies to you has been answered.
You have entered “unknown” in any answer space for which you were unable to answer a question.
You have signed and dated the statement.
You have included all the needed proofs.
When you received this statement, you should also have received a pre-addressed return envelope. If you do
not have this envelope, you can use any envelope as long as it is addressed to the RRB office shown on page
11 of this statement. No matter which envelope you use, you must put the correct postage on the envelope.
Be careful to provide enough postage, because this statement and the accompanying forms may weigh more
than a standard letter. The U.S. Postal Service will not deliver this statement unless it has the correct postage.
Make one final check before you seal the envelope to ensure that the following are enclosed:
NEEDED PROOFS
THE STATEMENT ITSELF
ADDITIONAL FORMS YOU WERE ASKED TO COMPLETE
Note: Make no entries on page 11, which is the receipt for your statement. After the RRB receives
this statement, they will complete the items on the receipt and send it back to you. When it is returned
to you, you will know that the RRB has received this statement and has started the work needed to
determine if you are entitled to increased benefits. If you do not receive the receipt within a month
after you filed this statement, please contact us so we can find out what is causing the delay.
Form G-319 (03-18)
Page 10
Receipt For Your Statement
Your Name
RRB Employee’s Name
Railroad Retirement Board Claim Number
Date Claim Received
A
Your statement for a Special Guaranty computation has been received and will be processed as quickly as possible. If you
change your address, or if there is some other change that may affect your claim, you or your representative should report that
change. The changes to be reported are listed below. Always give us your RRB claim number when writing or calling about your
claim. If you have any questions about your claim, we will be glad to help you. If you need to personally visit one of our field
offices, please call for an appointment. You will not be refused service if you do not have an appointment, but our staff can serve
you better when an appointment is made. Railroad Retirement Board offices are open to the public from 9:00 AM to 3:30 PM on
Monday, Tuesday, Thursday, and Friday, and from 9:00 AM to 12:00 PM on Wednesday.
Always Report These Changes To The RRB
l
l
ADDRESS - If your address changes. To avoid delays in
receipt of payments and RRB correspondence, you
should also file a regular change of address with your
U.S. Post Office.
l
EARNINGS - If anyone included in the family group for
the Special Guaranty computation, who is subject to the
annual earnings exempt amount, has earnings that
change from the amount you reported.
l
l
On your statement you told us that in the year _________:
l
l
Each family member will earn less than their own annual
earnings exempt amount.
l
_________________________ will earn $ _________
in employment or self-employment; and , either:
l
l
l
will earn more than $ ___________ each month or
will be performing substantial service in self-employment
each month.
PUBLIC SERVICE PENSION - If the spouse included in
the annuity computation begins to receive a public
service pension or the public service pension amount
changes.
CHILD STATUS - If a child included in the annuity
computation marries, dies, or leaves the spouse’s
custody.
SOCIAL SECURITY BENEFITS - If you or a family
member begin to receive social security benefits
directly from the Social Security Administration.
MARRIAGE ENDS - If your marriage ends by death or
divorce.
CRIMINAL OFFENSE - If you or a family member are
confined to a jail, prison, penal institution or correctional
facility due to a conviction for a criminal offense.
is)(is not) performing
How To Report Changes
When a change occurs, you should report the change at once. You or your representative can make your reports either by
telephone, mail, or in person, whichever you prefer.
In addition, an annual report of earnings must be filed with the RRB within 3 months and 15 days after the end of any taxable
year in which you or a family member earned more than the annual earnings exempt amount. The annual report of earnings is
required by law and failure to report may result in the loss of one or more monthly benefits.
To report any of the above changes, contact:
%
TELEPHONE NUMBER:
If for some reason you cannot contact that office, you should contact:
U.S. RAILROAD RETIREMENT BOARD
844 N. RUSH STREET
CHICAGO, IL 60611-1275
Page 11
Form G-319 (03-18)
Important Notices
Paperwork Reduction Act and Privacy Act Notices
Department of Veterans Affairs, or Federal, state, or local
welfare or public aid agencies to determine if you can
receive benefits from these organizations and if any
previous benefits were paid incorrectly.
This notice is given under the Paperwork Reduction Act of
1995 and the Privacy Act of 1974. The Privacy Act requires
that the Railroad Retirement Board (RRB) tell you the
following whenever we ask you for information:
8) The Internal Revenue Service or to state and local
taxing authorities for figuring your taxes and for use in audits.
1) The law which allows us to ask for information;
2) whether that law requires you to give us that
information and what, if anything, might happen to you if
you do not give it to us;
9) Your last address and the name of your last employer
may be released to the Department of Health and Human
Services to be used in the Parent Locator Service.
3) the reason why the information is requested; and
10) The Government Accountability Office for audits and
for collecting overpayments owed to the RRB or the
Social Security Administration.
4) the persons, organizations, and agencies to which we
may release the information without your permission.
11) The U.S. Department of Labor as required by the
Federal Coal Mine and Safety Act.
The RRB’s authority for requesting this information is
Section 7(b) of the Railroad Retirement Act of 1974.
Providing us with this information is voluntary on your part.
However, if you fail to provide us with the requested
information we may be unable to pay you any benefits. The
RRB needs this information to determine whether you are
eligible to receive such benefits and, if so, the amount you
are entitled to receive. If your Special Guaranty computation
is approved and we begin to pay you benefits, information
that we may request from you in the future will be used to
determine whether you are entitled to continue to receive
such benefits.
12) In certain cases for law enforcement purposes and for
court proceedings.
13) Information about the determination and recovery of
an overpayment made to you may be released to any
other person from whom any portion of the overpayment
is being recovered.
14) Your name and address may be released to a
Member of Congress to inform you about current or
proposed legislation which could affect the railroad
retirement system.
Although the information we request is almost never used
for any purpose other than the payment of benefits under
the Railroad Retirement Act, the RRB does have the
authority to release information to the indicated individuals,
organizations, and/or agencies listed below without your
approval:
1) An attorney, the Office of the President, a
Congressional office, a labor union or the Department of
State’s embassy or consular offices if they allege to be
representing you at your request.
2) Other people who are receiving benefits based on the
same railroad retirement account as you are if the
information affects their payments from the RRB.
3) A person who will receive benefits on your behalf if the
RRB decided that some medical condition keeps you from
receiving your own benefits; such information may also be
released to determine whether such a medical condition
exists and who is suitable to receive such benefits for you.
4) People or organizations who are working for the RRB;
such information may include medical records.
We estimate this form takes an average of 26-55 minutes
for an employee and 30-60 minutes for a spouse 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 Street, Chicago, Illinois
60611-1275.
Computer Matching and Privacy Protection Act Notice
5) The U.S. Treasury Department or U.S. Postal Service
to issue payments and to investigate lost, forged, or
stolen checks.
6) Your last employer (or to its insurance company) to
make sure that you can receive any private retirement or
insurance benefits which may be offered by the employer.
7) The Social Security Administration, Centers for
Medicare & Medicaid Services, Pension Benefit
Guarantee Corporation, Office of Personnel Management,
Form G-319 (03-18)
15) Professional Standards Review Organizations and
State Licensing Boards when services provided by
physicians or practitioners suggest unethical or
unprofessional conduct.
The Computer Matching and Privacy Protection Act of 1988
requires the Railroad Retirement Board (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.
Page 12
| File Type | application/pdf |
| File Title | g-319 (7-00).qxd |
| Author | OSIKAGL |
| File Modified | 2018-04-03 |
| File Created | 2002-11-21 |