G-99C (proposed) Representative Payee Evaluation Report

UNITED STATES OF AMERICA
RAILROAD RETIREMEW BOARD

FORM APPROVED

O.M.B. NO. 32200151

REPRESENTATIVE PAYEE EVALUATION REPORT
RR EMPLOYEE'S NAME
FROM:

I

TO:

I

CURRENT RATE

I

I

TOTAL YEARLY AMOUNT

*&

I

NUMBER

-

I

E

Wf ,@cIAIM

PAYEE'S NkME

NUMBER

ANNUITANT'S NAME

We estimate thls form takes between 24 and 31 minutes
nd reviewing the completed form
getting the needed da
m including suggestions for red
other aspecgof this
Railroad Retirement Board, 844 N Rush St, Chicago IL 60611-2092.

ing the instructions,
our estimate or any
rces Management,

f'37

PART I - INFORMATION FROM PAYEE
DATE CONTACTED

PAYEE'S ADDRESS

I

1. GUARDIANSHIP STATUS

r\

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

I

b

(

N@O

Guardian's Address

1

2. CUSTODY
(a) Did the annuitant live alone or with som
other than the payee throughout the r c @ ] o d ?
~&res&f Custodian
(b) Name of Custodian

1

0

rnpletd;?bi

JI

~ e o r n ~ l e2Jtb)e and
Relationship
to Annuitant

Reason for
Change

Dates of
Residence

I

3. DEMONSTRATION OF CONCERN

I

(a) How did the payee learn of the a n n u i f m k e d s ?

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

--

A

f R

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

horn funds were give

1

.

1.

(a) Has the payee turned over
checks or the full amount of the
_I?
payments to another party?

d

1

r)a

tnT

Kc;

o

k e s - &*whom
m ~ i r e c t l ~annuitant
to
i To custodian

funds were g i v e s

I2 No

f

0 ~ @ x ~ l a n a t i of
o nuse:

(c) What dollar amount was used for the annuitant's care and maintenance?

1

&y

I

4. USE OF BENEFITS

(b)
. . Has the pavee used anv of the
railroad ietiement benefits
for hislher own use?

a No -&+Explain

1

$

-

(d) Was this dollar amount paid to
another ~artv?
. .

0 Y e a ; whom:

0

No

FORM G-99C (05-03)

I
I

4. USE OF BENEFITS (continued)

(e) What amount was used for the annuitant's clothing?
If less than $20, or more than $300, explai* ')

$

(f) What amount was used for the annuitant's
personal spending? If less than $300, e x p l a i n

$

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

$

-

-

I

0

(h) Total amount of benefits use

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

Explain:

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

\P

a

-

Yes-Verify any unusual or expensive purchases.
No Explain importance of record keeping.

5. CONSEUED FUNDS

1

mount of conserved funds

!

mount of conserved funds

O

ill

C h e p i v account

$

U.S. Savings Bonds
Savings Account

(c)
. . How d\ aAn d /e' r v e d funds desiclnated?

+ 1

1 NAMEAND ADDRESS OF BANK 1

PE OFMLDING
REGISTRATION

VABenefits

ACCOUNT NUMBER

SS Benefits

Public assistance (Explain)

a Yes

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

Address

Complete 6 (d)

No Go to 7

I

hone Number

I

la) What were the offenses for which vou were convicted?
(b) On what date(s) were you convicted?
(c) What waslwere your sentenc

-

(d) If imprisoned, when were you released?
ill the probation end?
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 p a p m necessary)

w'
IRM G-99C (05-03)

PAGE 2

I

-

PART II INFORMATION ABOUT ANNUITANT
1. ALL CUSTODY SITUATIONS

I

I
I

I

(b) Did the annuitant participate in decisions on expenditures?

0

Yes

(c) Did the annuitant receive funds V?

0

Yes

a
a
a

(d) Were any large purchases made for the annuitant?

IJ

Yes

Cl

(a) Is the annuitant aware of entitlement to railroad retirement benefit?

Yes

(e) Does the annuitant have any unmet needs?

I

No
No

'I

No
No

0

plain in REMARKS

w
y
(f) Does the annuitant live with someone o t h e r M the payee?

-

(g) Does the annuitant live alone?

%Ye

2. ANNUITANT NOT IN PAYEE'S CUSTODY

a

~ e @ o to 2
V,

No

No

Wnd
?

No

Conclude
interview

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

O
C ] ~ & k ~ x p l a i nin REMARKS
(b) Did anyone other than the payee show
concern for the annuitant?

1

0

~ ~ H d e n t iindividual,
f y
type-qf contact
e e e q u e n c yi". R'EMARKS~
N~

I

3. ANNUITANT LIVED ALONE

-

0
O

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

Annuitant
Payee'
0thef:l

-

0
0 Annuitant

(b) Who purchased the annui
food and clothing?
4. REMARKS (Continue on a separate sheet of p a p a necessaM

-

I
DATE CONTACTED

1

I

PART 111 INFORMATION FROM CUSTODIAN
CUSTODIAN'S NAME

ADDRESS

SHONE
NUMBER
I

1. CUSTODIAN NOT THE PAYEE

0
O

(a) Did the annuitan
during the entire

y e @ r n p l e t e 17e)
No
omplete gb), (c), and (d)

w

(b) Identify the other known custodians.
Name

Address

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

Phone Number

I

FORM G-99C (0503)

PART Ill (continued)

\

1. CUSTODIAN NOT THE PAYEE (continued)

I

I

(d) Why wag the annuitant's custody changed?
(e) Whom would the cu

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

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

personal use funds?
funds mingled with the funds
Yes

(k) Are the funds clearly designated as
the annuitant\?

O No

2. REMARKS (Qntinue on a separate sheet of papetjif necessa*

--

.

The information you provide on this form may be disclosed without your approv
information may also be disclosed without your approval to the General Accounting
owed to the RRB or the Social Security Administration, to law enforcement agencie
vou 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 benefh by the RRB, I affirm that to the best of my knowledge, the information I have given is true, wmplete 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)

SIGNATURE AND TITLE

FORM G-99C (05-03)

FIELD OFFICE

PAGE 4

DATE

I

I