Form G-45 Supplement to Claim of Person Outside the United States

United States of America
Railroad Retirement Board

Form Approved
OMB NO.3220-0155

Railroad Retirement Claim Number

SUPPLEMENT TO
CLAIM OF PERSON
OUTSIDE THE UNITED STATES

Railroad Employee's Social Security Number
Railroad Employee's Name

PAPERWORK REDUCTlONlPRlVACY ACT NOTICE

This notice is given under both the Papenvork Reduction Act and the Privacy Act. The information requested in this form is used to determine
whether your country of residence or your citizenship status will affect your Railroad Retirement Act benefits. The Railroad Retirement Board's
authority for requesting this information is Section 7b(6) of the Railroad Retirement Act.
Providing the requested information is voluntary, except as noted below. However, if you fail to provide us with such information,we will be unable
to pay you any benefits. Moreover, your obligation to provide us with the above information becomes mandatory when your refusal to disclose this
information reflects a fraudulent intent to obtain benefits not authorized by law. Under these circumstances, your refusal to provide us with this
information may be punishable by fine or imprisonment, or both.
We estimate this form takes an average of 10 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 regardingthe accuracy of our estimate or any other
aspects of this form, including suggestions for reducing completion time, to the Chief of Information Resources Management, Railroad Retirement
Board, 844 North Rush Street, Chicago, Illinois 60611-2092.
is orm is to e corn ete y or on e a o a person w o is, or wi e outsi e t e nite tates or
ays or more.
F
:~
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iutside thebunitecktatkif physiiklk !uiide the 50 ltates, the bktrict of%ohn:ia,
pdzrto RiLo, ?U
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..
Virgin
Islands, Guam, and American Samoa. If additional space is needed use ltem 8, Remarks.
If Person Has U.S.
Country(ies)
1.
Country of Residence
List below the full name of each
Country
Passport, list:
of Present
beneficiary in the same household
Citizenship
of
Passport
Date
Over Next
who is, or will be outside the U.S.
Birth
Present
(or at time of
No.
Issued
12 Months
death)
(a)

-

(b)
(c)
NOTE: All persons listed above or their representative payees must sign the certificate on the reverse side of this form (Item 9).

2. If any beneficiary listed in Item 1, above, was outside the U.S. this month or any of the past 18 months, or will be in the next 6 months,
complete ltem 2 by entering the name of the beneficiary and the dates (month and year) helshe was or will be outside the U.S.
Name

From

Date of Expected Return
to U.S.
(if within the next 6 months)

Outside U.S.

Outside U.S.

From

To

To

(a)
(b)
(c)

3. Has any person listed in ltems 1 or 2, above, been employed or selfemployed outside the U.S. in the past 12 months? If "Yes," give name
and date(@ work began.
Name

NO

YES

NO

Date(s)

Name

Date(s)

Name

Date(s)

4. Does any person listed in ltems 1 or 2, above, expect to begin
employment or self-employment outside the U.S. in the future? If "Yes,"
give name and date(@ work is expected to begin.
Name

YES

Date(s)

Name

Date(s)

Name

Date(s)

(Continued)

G-45 (10-01)

5.

Total
Number of
Years
Lived
in the U.S.

List Below the
Full Name of
Each Beneficiary
Listed In Item 1

Relationship
to Railroad
Employee
During
this Period

Dates Person Resided in the U.S.
From

To

From

To

MonthNear

MonthNear

MonthNear

MonthNear

(a)
(b)
(c)
NOTE: If additional space is needed use ltem 8, Remarks.
6. Answer onlv if the railroad emplovee is deceased. Did the railroad employee die while in the military
NO
service of the U.S. or as a result of disease or injury incurred or aggravated in the military service?
7. Medicare medical insurance (Part B) generally is payable only for medical services provided inside the U.S. If anyone listed in ltem 1 is
now enrolled in Medicare medical insurance (Part B) and wishes to terminate Part B enrollment, enter their name here.
Name
Name

OYESq

8. Remarks (Use this space for additional comments and explanations. If you need more space, attach a separate sheet.)

CERTIFICATION
I agree to notify the Railroad Retirement Board promptly if I (or any person for whom I receive benefits) become employed or self-employed
while outside the U.S., change citizenship, or go (for more than 30 days) into any country other than that indicated in ltem 9e.
I certify that all the information I have provided in completing this form is true to the best of my knowledge. I know that, if I have made a
false or fraudulent statement on this form, or if my refusal to provide this information reflects a fraudulent intent to obtain benefits not
authorized by law, I am committing a crime which is punishable under Federal law by fine or imprisonment, or both.
(b)
9. (a) Signature (First Name, Middle Initial, and Last Name) of Each
()'
Telephone Number
Date
Person Listed in Item 1. Representative Payees Must Sign for
Where You May Be
Minors and for Incapable or Incompetent Adults. (Write in Ink)
Contacted During the Day
(1
(2)
(3)
(d) Address (Where checks should be mailed while you are abroad)
Number and Street

Postal Code

&C

Countrv

NOTE: If more than one mailing address is required, use ltem 8, Remarks, and show names for each address.
(e) Residence Abroad (If checks are sent to a bank or Post Office Box or if your check mailing address is not your residence, provide
your residential address)
Postal Code
Country
Name
City
Number and Street
(1)
(2)
(3)
Explain in ltem 8, Remarks, why checks cannot be sent to your residence. If you use an APOIFPO address, explain why you do not
have a residential address.
10. If this application has been signed by mark (X) in ltem 9, two witnesses who know the signer(s) must sign below, giving their full
addresses.
(a) Signature of Witness
(b) Signature of Witness
Address (Number and Street)
City

Postal Code

Address (Number and Street)
Country

City

Postal Code

Country