Form G-346 (XX-XX) Employee's Certification

United States of America Form Approved

Railroad Retirement Board OMB No. 3220-0140

Only printed if application being filed is for a spouse annuity and employee application is not being filed at the same time and entry on Summary screen is not equal to “V.”

DO NOT WRITE ON THIS LINE

Reviewed by:

_________________________

EMPLOYEE’S CERTIFICATION

INSTRUCTIONS

Review the information entered by the Railroad Retirement Board (RRB) for accuracy. Use ink to complete any items that have not already been completed or that are completed incorrectly. If the information is not correct, cross out the incorrect information and enter the correct information above it. Initial and date all changes. If you need more space than is provided, use the Remarks section for that purpose. If you do not know the answer to a question, print “unknown” in the space provided.

After you have signed and dated this form, return it to the RRB using the enclosed envelope.

EMPLOYEE INFORMATION

1. Railroad Retirement Claim Number

2. Employee’s Social Security Number

3. Employee’s Name

YOUR MARRIAGE INFORMATION

4. I am currently married to: (Prefilled from spouse application.)

5. I was not married before my current marriage. (Prefilled from employee application if previously married question is answered “No.”)
   

6. Were you married before your current marriage? (Printed if employee application is not on APPLE.)

7. The following is a list of my marriages before my current marriage.

Date Began Spouse’s Name Ended by Date Ended

99/99/9999 xxxxxxxxxxxxxxxxxxxx xxxxxxxxxxx 99/99/9999

(Printed if employee application is on APPLE and previously married question is answered “Yes.”)

8. If there are any marriages not listed above, print the following information about your previous marriages, beginning with the most recent one.

Date Began Place Spouse’s Name Ended by Date Ended Place

(Printed if employee application is on APPLE and previously married question is answered “Yes.”)

9. If you were previously married, print the following information about your previous marriages, beginning with the most recent one.

Date Began Place Spouse’s Name Ended by Date Ended Place

(Printed if employee application is not on APPLE.)

REMARKS

This section is to be used for the continuation of answers to other items. You may also use this space to enter any additional information that you feel may be important to include.

Only print if employee filed for disability or application is not on APPLE
RELINQUISHMENT OF RIGHTS BY DISABILITY ANNUITANTS AND CERTIFICATION
I recognize that my spouse may not begin to receive an annuity while I hold rights to return to work for a railroad employer. By signing this statement, I authorize the RRB to relinquish any rights I may have to return to work for a railroad employer. Based on this authorization, my rights will be relinquished if my spouse becomes entitled to a spouse’s annuity. I understand this authorization remains in effect unless I revoke it in writing.

CERTIFICATION

I know that if I make a false or fraudulent statement or withhold information, in order to receive benefits from the RRB, I am committing a crime which is punishable under Federal law which may be punishable by include fines, imprisonment, or both.

I certify that the information I gave the RRB on this certification is true to the best my knowledge.


_________________________________ ___________________
Signature (First Name, Middle Initial, Last Name) Date (Month/Day/Year)

Daytime Telephone Number (_____)______________________

If this certification is signed by mark (“X”), two witnesses who know the person signing must sign below, giving their full addresses and daytime telephone numbers.

__________________________________ _______________________________
Signature of Witness Signature of Witness

__________________________________ _______________________________
Address (Street, City, State and ZIP Code) Address(Street, City, State and ZIP Code)

(_____)___________________________ (_____)________________________
Daytime Telephone Number Daytime Telephone Number

Paperwork Reduction Act and Privacy Act Notices

The Railroad Retirement Board is authorized to collect the information on this form by Section 7(b)(6) of the Railroad Retirement Act. This information is needed to determine your spouse’s or former spouse’s entitlement to benefits under the Railroad Retirement Act. You are not required to provide the information requested by this form, however, your failure to do so may result in your spouse or former spouse not receiving these benefits.

We estimate this form takes an average of 5 minutes 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: Railroad Retirement Board, ATTN: Bureau of Information Services/Policy & Compliance, 844 N. Rush St., Chicago, IL 60611-1275.

RRB Form G-346 (XX-XX) Page 3