G-238 (07-20) Statement of Residence

CURRENT

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0021

RRB Claim No.

Statement
of Residence

Employee’s SS No.
Employee’s Name

Paperwork Reduction Act / Privacy Act Notices

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 3 to 5 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 aspects 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.

1. Your Full Name
2. Name of person whose residence(s) you are certifying
3. I certify that the person named above resided in the following places during the periods shown.
Note: Where residence in a period is unknown, show the period and enter “Unknown” under “City or Town.”
City or Town

County

State

Month

From

Year

Month

To

Year

4. Explain how you know where the person lived.

5. Certification: Failure to report or the making of a false or fraudulent report can 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.
Date (Month, Day, Year)
Signature of person making statement
Signature (First Name, Middle Initial, Last Name) (Write in Ink)

Daytime Telephone Number

(

)

Mailing Address (Number and Street, Apt. No., P.O. Box, etc.)
ZIP Code

City and State

County (if any)

6. If the certification is signed by mark (X) in Item 5, two witnesses who know the person signing must sign below, giving
their full addresses and daytime telephone numbers.
a. Signature of Witness
b. Signature of Witness
Address (Number and Street, City, State and ZIP Code)

Address (Number and Street, City, State and ZIP Code)

Daytime Telephone Number

Daytime Telephone Number

(

)

(

)

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