Representative Payee Evaluation Report

FORM APPROVED
O.M.B. NO. 3220-0151

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

REPRESENTATIVE PAYEE EVALUATION REPORT
RR EMPLOYEE'S NAME

REPORT PERIOD
FROM:

TO:

I

CURRENT RATE

1

PAYEE'S PHONE NUMBER

(

TOTAL YEARLY AMOUNT

1

RRB CLAIM
NUMBER

I

I ANNUITANT'S

SYMBOL

I

PREFIX

NAME

1
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 suggestions for 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

I

PAYEE'S ADDRESS

I

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

a Yes Complete 1 (b)

Guardian's Address

a No Go to 2
Guardian's Phone Number

I (---I

----

2. CUSTODY

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

1

a No Go to 4

a Yes Complete 2 (b) and 3

Address of Custodian

Relationship
to Annuitant

' Reason for

Dates of
Residence

Change

I

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?

a Yes Show type of contact and frequency: a No
a Visits
a Phone
a Letters
a Yes Show t o whom funds were given:
No
a
Directly to annuitant
a To custodian
a

Explain

Explain

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 ieti;rement benefits
for hislher own use?

a Yes
0

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

IJ

Yes Amount used:

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

I
I

(d) Was this dollar amount paid to
another party?

Yes Show to whom:

Ji

a No

No Explanation of use:

$

0

NO

I
I
I

FORM G-99C (05-03)

1

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, 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)]
$

0
0

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

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

5. CONSERVED FUNDS
(a) Show the total amount of conserved funds
$
(b) Show the total amount of conserved funds
0 Cash
0 U.S. Savings Bonds
0 Checking account
Savings Account

a

Other

0

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

REGISTRATION

NAME AND ADDRESS OF BANK

ACCOUNT NUMBER

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

0

Yes Complete 5 (e)

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

0

Yes

0
0

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

0

0

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.
0 Worker's Compensation
VABenefits
0 Public assistance (Explain)
0 Other (Explain)

a

a

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

0

SS Benefits

Yes Complete 6 (d)

Address

0

No Go to 7
Phone Number

(---I

----

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?

I
I
I

I

a

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

0

No

(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 imp"soned, when were vou released?
(e) If probation was ordered, when did or will the probation end?
(f) If charges are currently pending, please give the location of the court in which the charges are pending, and the court docket number, if known.

1
I

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

FORM G-99C (05-03)

PAGE 2

r
I

-

PART II INFORMATION ABOUT ANNUITANT

1

DATE CONTACTED

1. ALL CUSTODY SITUATIONS
(a) Is the annuitant aware of entitlement to railroad retirement benefit?

0 Yes

I2 No

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

0 Yes

O No

(c) Did the annuitant receive funds for the annuitant?

0 Yes

a

No

Q

No

I
I

(d) Were any large purchases made for tFannuitant?

Q Yes

(e) Does the annuitant have any unmet needs?

IJ

(

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

Q Yes Go t o 2

0 No

(g) Does the annuitant live alone?

I l l Yes Go to 2 and 3

I2 NO

Yes Explain in REMARKS

No

Conclude

2. ANNUITANT NOT IN PAYEE'S CUSTODY
(a) Did the payee maintain contact with the annuitant?

Q Yes

Show type of contact and frequency.

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

1

Q No

Explain in REMARKS

Q Yes

Identify individual, type of contact
and frequency i n REMARKS.

Q

N~

3. ANNUITANT LIVED ALONE
Q Annuitant
Q Payee
Q Other

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

O Annuitant
Q Payee

(b) Who purchased the annuitants
food and clothing?

Q 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

----

I.CUSTODIAN NOT THE PAYEE

I

(a) Did the annuitant live with the custodian
during the entire report period?

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

a

(b) ldentify 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)

I

(d) Why was the annuitant's custody changed?
(e) Whom would the custodian notify in cases
of emergency?

Ll

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

Ll Yes
Ll No
Ll Yes

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

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

$

Ll

Ll Visits. How frequently?
Providing clothing
Other
No

a

Yes
-

(j) Are the annuitant's funds mingled with the funds
of other persons?
(k) Are the funds clearly designated as
the annuitant's?

1

Explain in REMARKS

$

Ll No
Ll Yes Go to I(j)

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

I

Payee
Other

-

a

No

Ll
Ll
Ll
Ll

Yes Go to I(k)
No
Yes
No

I

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

Paperwork Reductionlprivacy A c t 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 Reduction Act 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 infomlation 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 office 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 benetits by the RRB, I affirm that to the best of my knowledge, the information I have given is true, complete and correct.

I

PAYEE SIGNATURE

DATE

I

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