G-99C (01-09) Representative Payee Evaluation Report

FORM APPROVED
OM
...
B NO 3220~151

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

REPRESENTATIVE PAYEE EVALUATION REPORT
REPORTING PERIOD

RR EMPLOYEE'S NAME

FROM:

TO:

I TOTAL YEARLY AMOUNT

CURRENT RATE

RRB CLAIM NUMBER

IPAYEE'S TELEPHONE NUMBER

PAYEE'S NAME

I ANNUITANTS

NAME

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. Federal agencies may not conduct or sponsor, and respondents are not required to
respond to, a collection of information unless it displays a valid OMB number. If you wish, send comments regarding the accuracy of our esti­
mate or any other aspect 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

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

0

Yes - Complete 1(b)

0

No - Go to 2

I ~uardian's ~elePhone N_umb~ _ _

Guardian's Address

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

0

o

Yes - Complete 2(b) and 3

Address of Custodian

Relationship
to Annuitant

No -Got04

Dates of
Residence

Reason for
Change

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

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

DYes - Indicate type of contact and enter frequency.
Visits:
Telephone Calls:
Letters:

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

DYes - Indicate to whom the funds were given.
Annuitant
Custodian
Other:

o
o
o

o
o
o

o

No - Explain why not.

o

No - Explain why not.

o

No

o

No ­ Explanation of use.

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 his/her own use?

DYes - Indicate to whom the funds were given.
Directly to annuitant
To custodian

o
o

DYes - Enter amount used.

$

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

DYes - Enter to whom.

$

o

No
FORM G-99C (01-09)

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?

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

(h) Total amount of benefits used.

$

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) Enter the total amount of conserved funds.

$

(b) How are the total amount of conserved funds held?
0 Cash
0 U.S. Savings Bonds
0 Checking account
0 Savings Account

0

Other:

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

ACCOUNT NUMBER

NAME AND ADDRESS OF BANK

REGISTRATION

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

0

Yes - Complete 5(e)

0

No - Go to 6

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

0

Yes

0

No

0

No - Go to 7

0

No-Got07

6. OTHER INCOME
(a) Did the annuitant have other income which affects entitlement
to or use of railroad retirement benefits?
(b) Indicate the type(s) of other income.
0 Worker's Compensation
0 Public assistance (Explain)

0
0

VA Benefits
Other:

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

Address

0

Yes - Complete 6(b) and (c)

0

SS Benefits

0

Yes - Complete 6(d)

Telephone Number

(---)---­

.­

7. CRIMINAL OFFENSEIMISD.EMEANOR CONVICTIONS
Has the payee been convicted of a criminal or misdemeanor
offense under the statutes administered by the RRB or SSA
within the past fifteen years, or are charges for such an
offense currently pending in a court of law?

DYes - Complete 7(a)-(f)

0

No-Got08

(a) What waslwere the offense(s) for which you were convicted?
(b) On what date(s) were you convicted?
(c) What was/were your sentence(s)?
(d) If imprisoned, when were you released?
(e) If probation was ordered, when did or will the probation end?
(f) If charges are currently pending, enter 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.)

FORM G-99C (01-09)

PAGE 2

PART II • INFORMATION ABOUT ANNUITANT

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

0

Yes

0

No

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

0

Yes

0

No

(c) Did the annuitant receive funds?

0

Yes

0

No

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

0

Yes

0

No

(e) Does the annuitant have any unmet needs?

0

Yes - Explain in REMARKS

0

No

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

0

Yes - Go to 2

0

No

(g) Does the annuitant live alone?

0

Yes - Complete 2 and 3

0

No [ConClUde]
Interview

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

o

DYes - Indicate type of contact and enter frequency.

o
o
o

No - Explain why not.

Visits:
Telephone Calls:
Letters:

0

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

Yes - Identify individual,
type of contact, and
frequency in REMARKS.

0

No

3. ANNUITANT LIVED ALONE

o
o
o
o
o
o

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

(b) Who purchased the annuitant's
food and clothing?

Annuitant
Payee
Other:
Annuitant
Payee
Other:

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

PART III • INFORMATION FROM CUSTODIAN

DATE CONTACTED

CUSTODIAN'S NAME

TELEPHONE NUMBER

ADDRESS

<---} - - ­ -- - - ­
i. CUSTODIAN NOT THE PAYEE
(a) Did the annuitant live with the custodian
during the entire reporting period?

0

Yes - Go to 1(e)

0

No - Complete 1(b), (c), and (d)

(b) Identify the other known custodian(s). Use the REMARKS section on the next page, if necessary.
Name

Address

Telephone Number

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

FORM G-99C (01-09)

PART III (Continued)
1. CUSTODIAN NOT THE PAYEE (continued)
(d) Explain why the annuitant's custody
changed, then go to 2, REMARKS.
(e) Whom would the custodian notify in cases
of emergency?

(f) Did the custodian charge for the care

0
0
0

Payee
Other:

Explain in REMARKS

Yes - Enter amount charged.

and maintenance of the annuitant?

0

No

0

No

0

No

$

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

DYes ­ Indicate how.

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

0

o Visited - How frequently?
o Provided clothing
o Other:

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

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

(k) Are the funds clearly designated as belonging to
the annuitant?

Yes - Enter amount provided.

$

0

Yes

0

No

0

Yes

0

No

0

Yes

0

No

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

.Paperwork Reduction Act/Privacy Act Notices
This notice is given under the Paperwork Reduction Act of 1995 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 reporting period shown on the front of this fann. The
RRB's authority for requesting this information is Section 7(b) (6) of the Railroad Retirement Act of 1974.
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 infonnation 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, and to law enforcement agencies in court proceedings.
A complete listing of the persons, organizations. and agencies to which the information you have given us may be released is available at any office of the
RRB. if you wish to see it.

PART IV - CERTIFICA"rlON
I understand that civil and criminal penalties may be imposed on me for false or fraudulent statements. or withholding Infonnation to cause
payment of benefits by the RRB, I affinn that to the best of my knowledge, the infonnation 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.)

SIGNATURE AND TITLE

FORM G-99C (01-09)

FIELD OFFICE

PAGE 4

DATE