Form G-99D (12-05) G-99D (12-05) Parental Custody Report

Form Approved
OMB NO.3220-0176

UNITED
STATESOF AMERICA

RAILROAD RETIREMENT
BOARD
PAYMENT
ANALYSIS
AND SYSTEMS
844 NORTHRUSHSTREET
CHICAGO,
ILLINOIS
6061 1-2092

October 16, 2007

RRB Claim No.:
Annuitant's Name:
IMPORTANT: PLEASE READ THE INSTRUCTIONS INCLUDED IN THE PAPERWORK REDUCTION
ACTlPRlVACY ACT NOTICE PRINTED ON THE NEXT PAGE OF THIS FORM.
CHECK OR ENTER THE CORRECT ANSWER

Yes - Go to Item 6
No - Complete Items 2, 3,4, 5, and 6

1. Does the child live with you on a fulltime basis?
2. Provide the nearest estimate of the
percentage of time that the child
lives with you.

+

75% (3 weeks per month)
50% (2 weeks per month)
Less than 50% (less than 2 weeks per
month)

3. Provide the name, address, and daytime telephone number of your child's residence.

City, State, and ZIP Code:
Daytime Telephone Number: {
4. How often do you visit your child?

)
Daily
Holiday

Weekly
Yearly

Montl-~ly
Other -

5. Who is responsible for making
decisions regarding the child?
6. Certification - I understand that failure to report or the making of a false or fraudulent.report
can result in criminal prosecution or civil penalties, or both.
Signature

Date

Relationship to Annuitant or Title

s
Daytime Telephone Number

United States Railroad Retirement Board
Payment Analysis and Systems
844 North Rush Street
Chicago, Illinois 60611-2092

left. Foldproperly (right above
Item 5) so address appears in

Paperwork Reduction ActIPrivacv Act Notice

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 representative payee for the report period shown above. 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 can result in you
being asked to corr~pletea more detailed report and it may result in a suspension of benefit
payments or, ultimately, your removal as 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 3. 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 give us
may be released is available at any ofice of the RRB, if you wish to see it.
We estimate this form takes an average of 5 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 estimate or any other aspect of this form, including suggestions for reducing
completion time, to Chief of Information Resources Management, Railroad Retirement Board, 844
North Rush Street, Chicago Illinois 60611-2092.