G-124 (05-08) Statement of Marital Relationship

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0021

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Individual Statement of
Marital Relationship

RRB Claim No.:
Employee's SS No.:

I Employee's Name:

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Paperwork Reduction Act I Privacy Act Notices
The Railroad Retirement Board is authorized to collect the information
on this fonn under Section 7(b)(6) of the Railroad Retirement Act of
1974. The infonnation 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 infonnation is, therefore,
very much appreciated.
We estimate this form takes an average of 15 to 20 minutes per
response to complete, including the time for reviewing the instructions,

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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 infonnation 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 coinpletion time, to Chief of Infonnation Resources
Management, Railroad Retirement Board, 844 North Rush Street,
Chicago, Illinois 6061 1-2092.

Instructions: All questions must be answered or marked "Unknown." Type or print legibly in ink. If you need more space than
is provided to answer a question, use Item 23, Remarks, for this purpose.

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1 Your Full Name

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2 Full name of person you were living with

a Starting with the time you began living together as husband and wife, enter the places you lived and the dates you lived
there, then check ( d )whether you lived in each of the places together or separately. If you check "Lived Separately" also

I b Enter the reason(s) you did not live together continuously and the date(s).

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From
Year
Month

Reason(s)

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Did you have an understanding as to your relationship when you began living together?
If "Yes," answer Items a and b.

IJYes

To
Month

Year

IJNo

1 1 a If it was in writing. furnish a copy; if it was not in writing, what did you say to each other about your living together?
b Was this understanding later changed? If "Yes," describe the changes and when and

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why they were made.

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Did you have an understanding as to how long you would live together? If "Yes," what did
you say to each other about how long you would live together?

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Continued

Yes

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No

IJ Yes IJ No

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Form G-124 (05-08) Destroy prior editions

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Did you have an understanding as to how your relationship could end? If "Yes," what did
you say to each other on this subject?

Did you believe that your living together made you legally married? If 'Yes," why did you believe so?

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Q Yes

Q No

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Was there an agreement or promise that a ceremonial marriage would also be performed
in the future? If "Yes," explain why the ceremony was not performed.

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Yes

Q NO

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Were any children born of this relationship? If "Yes," list below.

a Yes

Q No

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Name

Date of Birth

Place of Birth

a By what names were you and the person you were living with known?
Man's Full Name

Woman's Full Name

(1) Before you lived together.
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(2) Since you lived together.
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b If you both did not use the same last name after you began living together, state why.

11 After you started living together, were there any legal papers created with both your names

Q Yes

such as deeds, insurance policies, bank accounts or contracts signed? If "Yes," list below.
Note: If you have copies of such documents, furnish them with this form.
Type of Document

Date Made

Q No

Were you shown as the other's husband or wife?

0 Yes Q
0 Yes Q
Q Yes
12 Did you have joint business dealings with other persons or joint charge accounts in stores?
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Address

Name of Person or Store

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No

Q No

0 Yes Q

If "Yes," give the name and address of such person or store and the date of the transaction.

No

No

Date of Transaction

13 a How did you introduce the person you were living with to relatives, friends, neighbors, business acquaintances and others?

b How did that person introduce you to relatives, friends, neighbors, business acquaintances and others?

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Form G-124 (05-08)

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14 How was mail addressed to you?

15 List below the names and addresses of any employers and neighbors who knew of your relationship.
Name

Address

I List below your closest relatives (other than children) who knew of your relationship.
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a Name

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Relationship to you

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Relationshipto you

Address

c Name

Relationshipto you

17 List below the closest relatives (other than children) of the person you were living with who knew of your relationship.
Relationshipto person you were living with

a Name
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Address

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Relationship to person you were living with

b Name
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Address

c Name

Relationshipto person you were living with
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Address

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One or more of the employers, neighbors, andlor relatives shown above may be contacted regarding knowledge they may have of

1 your marriage. If you object to us contacting any of the above, please list their name(s) and give the reason(s) for your objection(s).
REASON

NAME

19 Did you ever live with anyone else as husband and wife? If 'Yes," complete Items a and b, below.
a Name of Person

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Date Relationship Started

Date Relationship Started

m Yes a No

Kind of Relationship (Ceremonial, etc.)

I How Relationship Ended

I Date and Place Relationship Ended

b Name of Person

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Kind of Relationship (Ceremonial, etc.)

1 How Relationship Ended

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/ Date and Place Relationship Ended
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Form G-124 (05-08)

20 Did the person you were living with ever live with anyone else as husband and wife?
If "Yes," complete ltems a and b, below.
a Name of Person

Q Yes

Q No

Kind of Relationship (Ceremonial, etc.)
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How Relationship Ended

Date Relationship Started

Date and Place Relationship Ended
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b Name of Person

Kind of Relationship (Ceremonial, etc.)
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How Relationship Ended

Date Relationship Started

Date and Place Relationship Ended

1 Answer ltem 21 if either of vou had an earlier ceremonial or common-law marriaae that is still in effect or that ended after vou beaan livina toaether. I

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At the time you began living together did you know that the earlier marriage was still in effect?
If "No," answer ltems a and b, below.

Q Yes

a When and how did you first learn that this marriage was still in effect?

Month

Day

b When and how did the person you were living with first leam that this marriage was still in effect?

Month

Day

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Q No

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Year
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Answer ltem 22 only if either of you had an earlier ceremonial or common-law marriage that ended after you began living
- together.
Month
22 a When and how did you first learn that this marriage had ended?

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Month

b When and how did the person you were living with first learn that this marriage had ended?
c After both of you learned that the earlier marriage had ended, did you say anything to
each other about your relationship changing? If "Yes," what did you say to each other?

Q

Year

Yes

Year
Year

Q No

(This space may be used for explaining any answers to the questions. If you need more space, attach a separate sheet.)
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.
Date (Month, Day, Year)

Signature of person making statement
Signature (First Name, Middle Initial, Last Name)

Daytime Telephone Number
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Mailing Address (Number and Street, Apt. No., P.O. Box, etc.)

City and State

County (if any)

ZIP Code
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25 If the certification is signed by mark (X) in ltem 24, 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)

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

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Daytime Telephone Number

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Form G-124 (05-08)

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Daytime Telephone Number
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