Form G-238 (10-02) G-238 (10-02) Statement of Residence

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0021

Statement
of Residence

I RRB Claim No.:

I

Employee's SS No.:
Employee's Name:

Paperwork Reduction Act I Privacy Act Notices
T h e Railroad Retirement Board is authorized to collect the
information o n 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 furnishingthe information
is, therefore, very much appreciated.
W e 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 infomration unless it displays a valid OMB
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 Chief of Information Resources Management,
Railroad Retirement Board, 844 North Rush Street, Chicago,
Illinois 606 11-2092.

1 Your ~ u l l ~ a m e
2 Name of person whose residence(s) you are certifying
3 1 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."
From
To
County
State
City or Town
Month
Year
Year
Month

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
aiven 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
'

I

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

City and State

ZIP Code

County (if any)

I

I

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 davtime telephone numbers.

a Signature of Witness

b Signature of Witness

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

Daytime Telephone Number

(

)

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

I

Daytime Telephone Number

(

)
Form G-238 (10-02) Destroy prior editions