Repayment by Credit Card

Repayment of Debt

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0169 can be found here:

Documents and Forms

Document Name Document Type
Form G-421F Repayment by Credit Card Form
G-421F Repayment by Credit Card G-421F (11-05).pdf Form

Information Collection (IC) Details

IC Title:	Repayment by Credit Card	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 255

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	G-421F	Repayment by Credit Card	G-421F (11-05).pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: Railroad Retirement Survivor and Pensioner Benefit System	FR Citation: 40 FR 36268

Number of Respondents: 200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	200	-100	300
Annual IC Time Burden (Hours)	17	-8	25
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.