G-238A (07-20) Statement Regarding Divorce or Annulment

CURRENT

United States of America
Railroad Retirement Board

Statement Regarding
Divorce or Annulment

Form Approved
OMB No. 3220-0021

RRB Claim No:
Employee’s SS No:
Employee’s Name:

Paperwork Reduction Act / Privacy Act Notice

The Railroad Retirement Board is authorized to collect the
information on this form under Section 7(b)(6) of the Railroad
Retirement Act of 1974. The information will be used to determine
entitlement to benefits under this Act. You are not required to provide
this information. However, your failure to do so may result in loss
of benefits for the applicant. Your cooperation in furnishing the
information is, therefore, very much appreciated.
We estimate this form takes an average of 10 minutes per response
to complete, including the time for reviewing the instructions, getting

Part 1

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.

To be completed by Applicant

To: (Name and Address—Custodian of Records)

From: (Name and Address—Applicant)

To support my application for benefits under the Railroad Retirement Act, I must submit a statement showing whether or not a
divorce was obtained. Please check the divorce and annulment records, complete and sign this form, and return it to me.
Period(s) for which records
Name of parties to divorce or annulment action
are to be checked
(include other names by which these parties may have been known)
From
To

and
and
and
and

Signature

Part 2

Date

To be completed by Custodian of Records

1 Were the divorce and annulment records checked for the entire period(s) shown above?
If “No,” explain:

2 Was a record of a divorce or annulment action found?
If “Yes,” show the date and type of decree issued:
Date:

o

Yes

o

No

o

Yes

o

No

Type of Decree:

3 Remarks

Certification: Failure to report or the making of a false or fraudulent report may result in criminal prosecution or civil penalties,
or both. I understand that civil and criminal penalties may be imposed on me for false or fraudulent statements, or for
withholding information to cause or prevent payment of benefits by the RRB. I affirm that to the best of my knowledge, the
information I have given is true, complete, and correct.
Signature and Title

Date
Form G-238a (07-20) Destroy prior editions