Representative Payee Report

Form Approved
OMB NO. 3220-0151

United States of America
Railroad Retirement Board

REPRESENTATIVE
PAYEEREPORT
October 16, 2007
RRB Claim No.

SSN

Annuitant's Name

Reporting Period

IMPORTANT: Please complete and return this form i n the enclosed envelope within 15 days. You should also
read and retain the Statement of Duties and Paperwork Reduction Act/Privacy Act Notices on pages 3 and 4.

1. Does the annuitant live with you?

0

YES

If NO, enter the name, address and phone number of the persons or institutions with whom the annuitant lived
during the reporting period.

NAME

ADDRESS

DAYTIME PHONE

NAME

ADDRESS

DAYTIME PHONE

2. Are you the court appointed guardian or fiduciary guardian of the annuitant? (Note: A court appointed guardian
or fiduciary guardian is a person appointed by a court to care for the financial affairs of a minor or incapacitated
individual.)

0 YES-Attach a copy of the most recent financial accounting documents you submitted to the court
and go to item 7. (Do not submit the document appointing you a s guardian.)
NO- Go to item 3.

3. Enter the total amount of railroad retirement benefits received by the
$

annuitant during the reporting period.

4. Enter the dollar amount of railroad retirement benefits used for the
annuitant's expenses during the reporting period.

$

5. Enter a breakdown of the total expenses entered in item 4 by the categories listed in
items 5(a) through 5(d).

a. RoornIBoard
c. MedicalDental Care
Form G-99a (04-07)

b. Clothing/Personal Spending

d. Other
PLEASE
RETURN

THIS FORM IN THE ENCLOSED ENVELOPE.

6. If there were surplus railroad retirement benefits a t the end of the reporting period, show how the balance
was held.
Cash $

Checking Account $

Other:

Savings Account $

$

$

(Description)
(Amount)
(Description)
(Amount)
NOTE: If surplus benefits were held in checking or savings accounts, indicate the title or ownership
registration of the account below.
0 "Your name for beneficiary's name"
0 "Beneficiary's name by your name"

0

Other (describe)

7.Have you used any of the railroad retirement benefits received by the annuitant during the reporting
period for your own expenses or requirements?
YES - Provide the following information:
Amount used $

a

Explanation of use:

a NO-Go to item 8.
-

8. During the reporting period, did the annuitant have income from any of the following sources?

a YES-Enter a n "X"in the appropriate box(es) and provide the requested information.
0 Social Security $

Amount

a Public Service Pension $
a Work $
0

Claim Number
Amount

Claim Number

Workers'
Compensation $
Amount

Amount

Claim Number

NO-Go to item 9

9. Have you been convicted of a criminal or misdemeanor offense under the statutes administered by the
Railroad Retirement Board or Social Security Administration within the past fifteen years, or are
charges for such an offense currently pending in a court of law?
YES-Complete items 9(a) through 9(Q below.
NO-Read the Certification Statement below, and
sign the form in the space provided.

a

a

a. What waslwere the offense(s)for which you were convicted?
b. On what date(s) were you convicted?
C.

What wadwere 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, please give the location of the court in which charges are pending, and the court docket
number, if known.
Location:

Docket Number:

CERTIFICATION STATEMENT: I understand that civil and criminal penalties may be imposed on me for false or fraudulent statements,
or for 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.

Sign
here

DATE

SIGNATURE

DAYTIME
PHONE(

Form G-99a (04-07)

1
Page 2

Paperwork Reduction ActIPrivacy 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 a s representative payee
for the reporting period shown on the form. The RRB's authority for requesting this
information is section 7(b)(6) of the Railroad Retirement Act.
Your obligation to provide the requested information is voluntary. However, your
failure to respond can result in your being asked to complete a more
detailed report and it may result in a suspension of benefit payments or
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 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 give us may be released is available a t any office of the RRB.
We estimate this form takes a n average of 18 minutes per response to complete,
including the time needed 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 the Chief of Information Resources Management, Railroad
Retirement Board, 844 North Rush Street, Chicago, Illinois 6061 1-2092.

Form G-99a (04-07)

Page 3

Representative Payee Duties
Use of benefits
You must use the railroad retirement benefits you receive for the annuitant in his or her best
interest. To do this you must keep yourself informed of what the annuitant needs.

-

Record keeping requirements
A s part of your responsibilities as a representative payee, you must keep careful and accurate
records regarding your receipt, disbursement and use of the annuitant's funds. Periodically,
you will be asked to complete a report which will include the following questions:
What was the amount of benefits on hand
a t the beginning of the year?

a

How did you invest the savings?

a Where did the annuitant live during the

How were the railroad retirement benefits
available during the year used for support
of the annuitant?

year?
a

What was the annuitant's amount of
income from other sources during the year?

How much of the railroad retirement benefits did you save for the annuitant?

Reporting to the RRB
The following changes must be reported by the representative payee to the RRB:
a You are discharged as legal guardian.

a The annuitant's address changes.

A legal guardian is appointed or guardianship changes.

The annuitant is outside the United
States for more than 30 consecutive days.

You a r e no longer responsible for the
annuitant's care.

The annuitant performs any work, including self-employment.

a

Your address changes.

a

You are convicted of a criminal offense.

a

The annuitant begins to receive a public
service pension, or there is a change in
the amount of the pension.

a The annuitant dies.
a

The annuitant is convicted of a criminal
offense.

The annuitant is restored to competency
by a court.

a An application for social security benefits

is filed by the annuitant.
a The annuitant marries, remarries, or

divorces.

a

A student annuitant graduates from high
school or ceases full-time school attendance.

a The annuitant leaves your custody and care.

Form G-99a (04-07)

a

Pdnred on recycled paper

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