G-88A.1 (09-18) Request for Verification of Date Last Worked

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

CURRENT
FORM APPROVED
0MB NO. 3220-0005

Request for Verification of Date Last Worked - (Month/Year) Retirements

The following is a list of your former employees who have recently filed an application for either an age and service or a disability annuity with the Railroad
Retirement Board (RRB). The employees provided their Date Last Worked for your railroad: and, if applicable, the ending date of any Pay For Time Lost after
the actual date last worked. If the employees are filing based on age and service, they provided their Date Relinquished Rights to railroad employment. The
dates the employees provided on their applications are shown below. If these dates are correct, there is nothing you need to do. But if any of these dates are
NOT correct, please cross them out and enter the correct date above them. When correcting a date, add an attachment explaining the correction.
Fax your correction to the Retirement and Survivor Benefits Division - Retirement Initial Section: (312) 751-7192.

BA
No

SSN

Payroll Name

Job Title

Dept-Div

Location

Date Last
Worked

Last Day of
Pay For Time
Lost, If Later
Than Date
Last Worked

Date
Relinquished
Rights, If
Applicable

(

CERTIFICATION: I understand that civil and criminal penalties can be imposed against me for false and fraudulent statements or for withholding information to misrepresent a fact material to
determine a right to payment under the Railroad Retirement Act. I certify that, to the best of my knowledge, the information which I have given is true, complete, and correct.

Signature:
Title:
Form G-88A.1 (09-18)

Date: