| Railroad Employee: |
_________________________________________ |
| Railroad Employee's SSA No: |
______________________________ |
I, _________________________, social security number, hereby claim the interest awarded to me in benefits payable to the above former railroad employee under the Railroad Retirement Act pursuant to the court document entered on [DATE], in the case entitled:______________________________.
I acknowledge that any payments to me pursuant to this claim are disbursements from the Treasury of the United States, and I agree to repay any erroneous payment made to me by the Railroad Retirement Board (RRB) pursuant to this agreement. I further acknowledge that no condition in the order or under relevant state law that requires termination of the payments made to me by the RRB pursuant to the order has occurred, and agree to inform the RRB if any such condition occurs in the future.
| Signed: |
______________________________ |
| Address: |
______________________________ |
| |
______________________________ |
| |
______________________________ |
| Date: |
______________________________ |
NOTE: The RRB will contact you regarding payments under the order at the address shown above unless a more recent address appears in the records maintained by the RRB under the social security number of the above-named railroad employee. If you have not been contacted by the time you attain age 62, you should contact the RRB.
Complete and return the form to:
Office of General Counsel
U.S. Railroad Retirement Board
844 North Rush Street
Chicago, IL 60611-1275
| Email: |
LAW@rrb.gov |
| Fax: |
(312) 751-7102 |
| Phone: |
(312) 751-4948 |
|