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UNITED S TATES OF AMERICA
RAILROAD RETIREMENT B OARD
FORM A PPROVED
OMB NO. 3220-0099
DO NOT WRITE IN THIS SPACE
OFFICIALLY FILED
MONTH
DAY
STATEMENT REGARDING
CONTRIBUTIONS AND SUPPORT
OFFICE NUMBER
YEAR
APPROVED
S ECTION 1 - GENERAL INSTRUCTIONS
The information requested on this form is authorized by Section 7(b)6 of the Railroad Retirement Act. The information asked for
in this form is necessary to determine your entitlement to benefits under the Railroad Retirement Act. You do not have to provide
the information requested. However, if you fail to do so, we may not be able to pay you benefits. We estimate this form takes an
average of 147-180 minutes per response, 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 the completion time to: Associate Chief Information Officer for Policy and
Compliance, Railroad Retirement Board, 844 North Rush Street, Chicago, Illinois 60611-1275.
INFORMATION REQUESTED ON THIS FORM IS FOR THE 12-MONTH PERIOD:
MONTH
DAY
YEAR
MONTH
WHICH BEGAN
DAY
YEAR
AND ENDED
Type or print all answers legible in ink. If you need more space than is provided to answer a question, use Section 6 for this
purpose. If you do not know the answer to a question, print “Unknown” in the space provided for the answer.
When entering dates, always use numbers. Also, be sure there is one number in each box. For example, you would enter
January 1, 2017, as:
MONTH
DAY
Y EAR
0 1 0 1 2 0 1 7
Some items in this application will not apply to you so you will not need to answer them. Based on your answers to a question,
you may be told to skip to another item number or section. Follow the instructions that tell you to “Go to” another item. They
are designed to help you move through the application form quickly and provide only necessary information. If no “Go to”
instructions are given, answer the next item in order. Do not skip any items unless directed to do so.
If you are completing this form on behalf of someone else, you must answer each question as it applies to the applicant.
SECTION 2 - IDENTIFYING INFORMATION
s s s
Check the information provided for Items 1 through 6 for accuracy.
If the information is correct, go to Section 3.
If the information is not correct, cross out the incorrect information and enter the correct information above it.
If the information is missing, fill it in.
EMPLOYEE
I DENTIFICATION
s
s
1 EMPLOYEE’S NAME
2 EMPLOYEE’S SOCIAL SECURITY NUMBER
3 EMPLOYEE’ S RAILROAD RETIREMENT CLAIM NUMBER
s
4 APPLICANT’S NAME
APPLICANT
IDENTIFICATION
5 a APPLICANT’S STREET ADDRESS
b CITY AND STATE
c ZIP CODE
d COUNTY
s
6 DAYTIME TELEPHONE NUMBER
Form G-134 (05-17) Destroy Prior Editions
S ECTION 3 - INFORMATION ABOUT A PPLICANT
BIRTHDATE
s
MONTH
7
DAY
YEAR
Enter your Date of Birth.
s
RELATIONSHIP
s
8
Enter an “X” in only one box to show your relationship to the employee.
s
s
O NE-HALF
S UPPORT
9
s
Enter an “X” in the appropriate box:
Did you receive one-half of your support from the employee
during the 12-month period?
o
o
o
Widower
o
o
Yes
Go to Item 10
No
Go to Section 7
Parent
Other
SECTION 4 - S UPPORT AND L IVING C OSTS
10
s
SUPPORT F ROM EMPLOYEE
11
Enter the total amount of the employee’s income during the 12-month period.
If you do not know, enter “Unknown.”
$
Enter the amount the employee contributed to your support during the 12-month period.
Include money and the value of goods and services such as food, clothing,
rent-free living or transportation that the employee provided for you.
$
12
Enter the frequency of contributions (weekly, monthly, irregularly, etc.)
13
Enter the date the employee last contributed.
14
If the employee’s contributions were irregular, varied in amounts, or stopped before the end of the 12-month period,
explain here. If you need more space, continue in Section 6.
15
Enter an “X” in the appropriate box:
Did you and the employee live together in the same household
during the 12-month period?
MONTH
DAY
YEAR
s
s
LIVING ARRANGEMENTS AND COSTS
16
Enter an “X” in the box next to each
month in which you lived with the employee
during the 12-month period shown on
the first page. If you did not live with the
employee in any of the 12 months, enter an
“X” in “None.”
o
o
Yes
Go to Item 18
No
Go to Item 16
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
NONE
Only complete Item 17 if you are the employee’s husband or widower. Otherwise go to Item 18.
17 If you separated and resumed living together during the 12-month period, state the facts and circumstances surrounding
the separation. If you need more space, continue in Section 6.
s
Form G-134 (05-17)
Page 2
18
s
19
o
o
Enter an “X” in the appropriate box:
Did you own the dwelling in which you lived
during the 12-month period?
21
Go to Item 23
No
Go to Item 19
Enter the name and relationship of the person who owned the dwelling in which you lived.
NAME OF OWNER
20
Yes
RELATIONSHIP TO YOU (IF NONE, ENTER NONE)
Enter an “X” in the appropriate box:
Did you pay either the rent or the costs of maintaining the property,
such as repairs, association fees, mortgages, and taxes?
o
o
Yes
Go to Item 23
No
Complete Items 21
and 22
Enter the name of each person who paid the rent or costs of maintaining the property; what each paid for; and how much.
NAME OF PERSON WHO PAID
ITEM PAID FOR
AMOUNT PAID
$
LIVING ARRANGEMENTS AND COSTS
$
$
22
Enter the monthly rental value of the dwelling in which you lived.
If unknown, estimate to the best of your ability.
23
Enter below information about anybody (other than the employee) who, during the 12-month period, either:
l lived with you; or
l contributed to your support or to the support of your household. Include as contributions:
l Payments for room and board, rent, or maintenance fees
l Cash given for support
l Payments for household expenses (insurance premiums, medical expenses, gifts, etc.)
l Food or clothing cost
$
If any of the contributions were for the support of other members of the household, use Section 6 or
a separate sheet to provide details.
Where applicable, enter “None.”
NAME
RELATIONSHIP TO
YOU
DATES THE
PERSON
LIVED
WITH YOU
TOTAL AMOUNT
OF CONTRIBUTIONS DURING
MONTH
THE PERIOD
DATE AND AMOUNT OF
LAST CONTRIBUTION
DAY
YEAR
AMOUNT
$
$
$
$
$
$
If no one listed in this item lived with you, go to Item 26.
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Page 3
Form G-134 (05-17)
SECTION 5 - O THER INCOME AND FINANCIAL A CTIVITIES
24 Enter the monthly cost, per person, of room and board you
provided to anyone who lived with you.
$
25 Enter an “X” in the appropriate box:
Do you have records of the cost shown in Item 24?
o
o
Yes
26 Enter an “X” in the appropriate box:
Did you, or a member of the household, receive some kind of
public or private aid during the 12-month period?
o
o
Yes
Go to Item 27
No
Go to Item 28
No
s
27 Enter the following information. Include payments for room and board, clothing, medical, household and other expenses.
NAME AND ADDRESS
OF AGENCY
TOTAL AMOUNT OF
CONTRIBUTIONS
DURING THIS PERIOD MONTH
DATE AND AMOUNT OF
LAST CONTRIBUTION
YEAR
DAY
INCOME
s
AMOUNT
$
$
$
$
$
$
$
$
28 Enter the following information about the income you received during the 12-month period.
SOURCE OF INCOME
DATE YOU LAST RECEIVED
INCOME AND AMOUNT
NET INCOME
MONTH
DAY
YEAR
AMOUNT
AND
OTHER BENEFITS RECEIVED
NAME OF PERSON FOR
WHOM AID WAS GIVEN
Wages, salary, commissions, etc.
$
$
Pensions, annuities, insurance (include
benefits under the Social Security and
Railroad Retirement Acts)
$
$
Stocks, bonds, securities, etc.
$
$
Trade, business, or self-employment
$
$
Real property
$
$
Farming or gardening (include value of
products raised and used in home)
$
$
Other sources of income (do not include
amounts shown in answers to previous
questions on this form)
$
$
Form G-134 (05-17)
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29 Complete this item if you deposited or withdrew funds from a bank account during the 12-month period.
BALANCE AT BEGINNING OF
12-MONTH PERIOD
s
OTHER FINANCIAL ACTIVITIES
OWNER(S) OF ACCOUNT
BALANCE AT END OF
12-MONTH PERIOD
$
$
$
$
30 Enter the amount and describe any other funds which were used for support, or put into savings, during the 12-month period.
If none, enter “None.”
31 Enter the description, date incurred, and amount of your debts at the end of the 12-month period. If none, enter “None.”
DATE INCURRED
DESCRIPTION
MONTH
DAY
AMOUNT
YEAR
$
$
s
S ECTION 6 - A DDITIONAL F ACTS AND R EMARKS
s
REMARKS
32 This section is to be used for the continuation of answers to other items. Be sure to include the item number at the beginning
of the answer you wish to continue. You may also use this section to enter any additional facts that tend to show you
received at least one-half of your support from the employee during the 12-month period shown in Section 1. If you need
more space for your answers, attach additional sheets.
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Form G-134 (05-17)
S ECTION 7 - CERTIFICATION
33 I understand that civil and criminal penalties may be imposed against me for false or fraudulent statements, or for withholding
or misrepresenting information in order to receive benefits from the Railroad Retirement Board. I certify that the information
provided to the Railroad Retirement Board on this application is true, complete, and correct to the best of my knowledge.
s
SIGNATURE
(First Name, Middle Initial,
Last Name)
MONTH
CERTIFICATION
DATE
DAY
34 If this certification is signed by mark (“X”) in Item 33, two witnesses who know the person signing must sign below giving their
full addresses and daytime telephone numbers.
a. SIGNATURE OF WITNESS
s
YEAR
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-134 (05-17)
)
Page 6
)
| File Type | application/pdf |
| File Modified | 2017-05-16 |
| File Created | 2002-10-16 |