G-99C (05-03) Representative Payee Evaluation Report

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

FORM APPROVED

O.M.B.NO. 32200151

REPRESENTATIVE PAYEE EVALUATION REPORT
REPORT PERIOD

RR EMPLOYEE'S NAME

FROM:

TO:

CURRENT RATE

TOTAL YEARLY AMOUNT

RRB CLAIM
NUMBER

SYMBOL

PAYEE'S NAME

EE'S CLAIM
NUMBER

PAYEE'S PHONE NUMBER

ANNUITANT'S NAME

(

PREFIX

I

)
We estimate this form takes between 24 and 31 minutes per response to complete, including the time for reviewing the instructions,
getting the needed data and reviewing the completed form. If you wish, send comments regarding the accuracy of our estimate or any
other aspects of this form including~suggestionsfor reducing completion time to: chief of Information Resources Management,
Railroad Retirement Board, 844 N Rush St, Chicago IL 60611-2092.

PART I - INFORMATION FROM PAYEE
DATE CONTACTED

PAYEE'S ADDRESS

1. GUARDIANSHIP STATUS

Cj

(a) Does the annuitant now have a legal guardian?
(b) Guardian's Name

Cj

Yes Complete 1 (b)

No Go to 2

1 Guardian's Phone Number

Guardian's Address

2. CUSTODY
(a) Did the annuitant live alone or with someone
other than the payee throughout the report period?
(b) Name of Custodian

1

Cj

Yes Complete 2 (b) and 3

Address of Custodian

Relationship
to Annuitant

Cj

No Go to 4

1

Dates of
Residence

Reason for
Change

3. DEMONSTRATION OF CONCERN
(a) How did the payee learn of the annuitants needs?

(b) Did the payee maintain contact
with the annuitant?

(c) Did the payee provide the
annuitant with funds for
personal spending?

IJ Yes
IJ Visits
IJ Phone
IJ Letters

Show type of contact and frequency:

a Yes Show to whom funds were given:
a
to annuitant
a ToDirectly
custodian

IJ No

Explain

No

Explain

I7

4. USE OF BENEFITS

(a) Has the payee turned over
checks or the full amount of the
payments to another party?
(b) Has the payee used any of the
railroad retirement benefits
for hislher own use?

a Yes Show to whom funds were given:
a Directly to annuitant
To custodian

IJ Yes

a No Explanation of use:

Amount used:

(c) What dollar amount was used for the annuitant's care and maintenance?
(d) Was this dollar amount paid to
another party?

a No

a Yes Show to whom:

$

a No
FORM G-99C (05-03

4. USE OF BENEFITS (continued)

(e) What amount was used for the annuitant's clothing?
If less than $20, or more than $300, explain
(f) What amount was used for the annuitant's
personal spending? If less than $300, explain

$

(g) Excluding savings, what amount was used for
expenditures other than maintenance, clothing and
personal spending?

$

1

(h) Total amount of benefits used

Explain:

Total amount [add (c) through (g)]
$

CI Yes Verify any unusual or expensive purchases.

(i) Did the payee record expenditures (receipts, cancelled
checks, etc.)?

CI No Explain importance of record keeping.

5. CONSERVED FUNDS

1

(a) Show the total amount of conserved funds

$

(b) Show the total amount of conserved funds
IJ Cash
CI U.S. Savings Bonds
CI Checking account
CI Savings Account

C) Other
C)

(c) How are conserved funds designated?
TYPE OF HOLDING

I

I

REGISTRATION

NAME AND ADDRESS OF BANK

I

(d) Are the funds mingled with the funds of another person?

Q Yes Complete 5 (e)

(e) Are the funds clearly recorded as belonging to the annuitant?

CI Yes

CI

ACCOUNT NUMBER

Q No Go to 6

No

6. OTHER INCOME

(a) Did the annuitant have other income which affects entitlement
to or use of railroad retirement benefits?
(b) Show the types of other income.
C) Worker's Compensation
CI VA Benefits
CI Public assistance (Explain)
C) Other (Explain)

0
CI

Yes Complete 6 (b) and (c)
No Go to 7

CI

SS Benefits

-

(c) Is there another payee for other income?
(d) Name of Other Payee

CI Yes Complete 6 (d)

Address

CI No Go to 7
Phone Number

(---)

----

7. FELONYIMISDEMEANOR CONVICTIONS

Has the payee been convicted of felony, or misdemeanor
offense(s) under the statutes administered by the RRB or
SSA, within the past fifteen years or are charges for such
offenses(s) currently pending in a court of law?

C) Yes Answer questions 7 (a) through (e) below

(a) What were the offenses for which you were convicted?
(b) On what date(s) were you convicted?
(c) What waslwere your sentences(s)?
(d) If imprisoned, when were you released?
-

(e) If probation was ordered, when did or will the probation end?
(f) If charges are w r G y pending, please give the location of the court in which the charges are pending, and the court docket number, if known.
8. REMARKS (Continue on a separate sheet of paper if necessary)

DRM G-99C (05-03)

PAGE 2

-

PART II INFORMATION ABOUT ANNUITANT
DATE CONTACTED
1. ALL CUSTODY SITUATIONS

(e) Does the annuitant have any unmet needs?

u
u
u
u
u

(f) Does the annuitant live with someone other that the payee?

O Yes Go t o 2

O No

(g) Does the annuitant live alone?

u

0

(a) Is the annuitant aware of entitlement to railroad retirement benefit?
(b) Did the annuitant participate in decisions on expenditures?
(c) Did the annuitant receive funds for the annuitant?
(d) Were any large purchases made for the annu~tant?

Yes
Yes
Yes
Yes

u
u
u
u

No
No
No
No

0

Yes Explain in REMARKS

Yes Go t o 2 and 3

No

No

Conclude

2. ANNUITANT NOT IN PAYEE'S CUSTODY

O Yes

(a) Did the payee maintain contact with the annuitant?

(b) Did anyone other than the payee show
concern for the annuitant?

u
u
u

Show type o f contact and frequency.

u
No

Explain in REMARKS

Yes

ldentify individual, type o f contact
and frequency i n REMARKS.

No

3. ANNUITANT LIVED ALONE

u Annuitant
u Payee

(a) Who was responsible for maintenance
expenses such as rent and utilities?

Other

u Annuitant

(b) Who purchased the annuitants
food and clothing?

D

Payee
Other

4. REMARKS (Continue on a separate sheet of paper if necessary)

PART 111 - INFORMATION FROM CUSTODIAN
DATE CONTACTED

CUSTODIAN'S NAME

ADDRESS

PHONE NUMBER

I.CUSTODIAN NOT THE PAYEE
(a) Did the annuitant live with the custodian
during the entire report period?

Ji

u

Yes Complete I(e)
No Complete I(b), (c), and (d)

(b) Identify the other known custodians.
Name

Address

Phone Number

(c) When did the annuitant begin
living with the custodian?
PAGE 3

FORM G-99C (05-03

PART Ill (Continued)
1. CUSTODIAN NOT 'THE PAYEE (continued)
(d) Why was the annuitant's custody changed?

Li

(e) Whom would the custodian notify in cases
of emergency?

a

Payee
Other
Yes

(f) Did the custodian change for the care
and maintenance of the annuitant?

Li

$

No

a Yes a Visits.
Li Providing clothing
a Other

(g) Did the payee show personal concern
for the annuitant?

Explain in REMARKS

How frequently?

Li No

Li

(h) Did the payee provide money for the annuitant's
personal use?

Li No

(i) Does the custodian hold and control the annuitant's
personal use funds?

Li
Li

Yes Go to 1 (j)
No

a

Yes Go to 1 (k)

(j) Are the annuitant's funds mingled with the funds
of other persons?

Yes

$

El No

(k) Are the funds clearly designated as
the annuitant's?

a

Yes

Li

No

2. REMARKS (continue on a separate sheet of paper if necessary)

Paperwork Reductionlprivacy Act Notice
Federal agencies may not collect or sponsor and respondents are not required to respond to a collection of information unless it displays a valid OMB number.
This notice is given under the Papework ReductionAct of 1980 and the Privacy Act of 1974. The information requested on this form is used by the Railroad
Retirement Board (RRB) to conduct an accounting of your performance as a representative payee for the report period shown on the front of this form. The
RRB's authority for requesting this information is Section 7 (b) (6) of the Railroad Retirement Act of 1974.
Please complete and return this form in the enclosed envelope within 15 days. Your obligation to provide the requested information is voluntary. However,
your failure to respond may result in a suspension of benefit payments or, ultimately, your removal as a representative payee.
The information you provide on this form may be disclosed without your approval to the individual or institution you identified in question number one. Such
information may also be disclosed without your approval to the General Accounting Office for audits, to the Justice Department for collecting overpayments
owed to the RRB or the Social Security Administration, to law enforcement agencies and in court proceedings.
A complete listing of the persons, organizations and agencies to which the information you have may be released is available at any ofice of the RRB, if
you wish to see it.

PART IV - CERTIFICATION
I understand that civil and criminal penalties may be imposed on me for false or fraudulent statements, or withholding information to cause
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.
PAYEE SIGNATURE

DATE

RELATIONSHIP TO ANNUITANT
CUSTODIAN SIGNATURE

DATE

PART V

- EVALUATION AND ACTION TAKEN

(continue on a separate sheet of paper if necessary)

IGNATURE AND TITLE

I R M G-99C (05-03)

FIELD OFFICE

PAGE 4

DATE