UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD
FORM APPROVED
OMB NO. 3220-0183
STATEMENT OF CLAIMANT OR OTHER PERSON
NAME OF RAILROAD EMPLOYEE
NAME OF CLAIMANT
(If other than railroad employee)
RELATIONSHIP TO CLAIMANT OF PERSON MAKING STATEMENT
DATE
(Month, Day, Year)
TELEPHONE NUMBER (Include Area Code)
MAILING ADDRESS (Number and Street, Apt., No., P.O. Box, Rural Route)
CITY, STATE, AND ZIP CODE
1. SIGNATURE OF WITNESS
ADDRESS
(Number and Street, City, State, and ZIP Code)
2. SIGNATURE OF WITNESS
ADDRESS
(Number and Street, City, State, and ZIP Code)
If this statement is signed by mark “X,” two witnesses who know the person signing must sign below, giving their full addresses.
Understanding that this statement is for the use of the Railroad Retirement Board (RRB), I hereby certify that:
SIGNATURE OF PERSON MAKING STATEMENT
(First Name, Middle Initial, Last Name) (Write in Ink)
SIGN
HERE
( ) If additional space is needed, mark an “X” and continue on the next page.
CERTIFICATION
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.
PLEASE READ THE “IMPORTANT NOTICES” ON THE NEXT PAGE
SOCIAL SECURITY NUMBER OF RAILROAD EMPLOYEE
RR RETIREMENT ANNUITY CLAIM NUMBER
(If different from
SS Number)
NAME OF PERSON MAKING STATEMENT (If other than claimant)
(continued) RRB FORM G-93 (09-18)
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