Representative Payee Evaluation Report

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

You can complete everything ABOVE Part I then TAB twice and enter your City/State

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

REPRESENTATIVE PAYEE EVALUATION REPORT
REPORTING PERIOD

RR EMPLOYEE’S NAME

FROM:

TO:
TOTAL YEARLY AMOUNT

CURRENT RATE

PAYEE’S NAME

RRB CLAIM NUMBER

PAYEE’S TELEPHONE NUMBER

ANNUITANT’S 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 estimate 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 l – INFORMATION FROM PAYEE
DATE CONTACTED

PAYEE’S ADDRESS

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

Yes - Complete 1(b)

Guardian’s Address

No - Go to 2
Guardian’s Telephone Number

( ___ ___ ___ )

___ ___ ___ – ___ ___ ___ ___

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

Yes - Complete 2(b) and 3

Address of Custodian

Relationship
to Annuitant

No - Go to 4

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?

Yes - Indicate type of contact and enter frequency.

Visits:

Telephone Calls:

Letters:

No - Explain why not.

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

Yes - Indicate to whom the funds were given.

Annuitant

Custodian

Other:

No - Explain why not.

Yes - Indicate to whom the funds were given.

Directly to annuitant

To custodian

No

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?

Yes - Enter amount used.
$

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

No - Explanation of use.

Yes - Enter to whom.

$ ________________________________________

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.

$___________________________________________________

Yes [Verify any unusual or expensive purchases.]

No [Explain importance of record keeping.]

(i) Did the payee record expenditures (receipts, cancelled
checks, etc.)?
5. CONSERVED FUNDS
(a) Enter the total amount of conserved funds.

$___________________________________________________

(b) How are the total amount of conserved funds held?

U.S. Savings Bonds

Cash

Savings Account

Checking account

Other: _______________________________

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

NAME AND ADDRESS OF BANK

REGISTRATION

ACCOUNT NUMBER

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

Yes - Complete 5(e)

No - Go to 6

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

Yes

No

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.

Worker’s Compensation

Public assistance (Explain)

No - Go to 7

SS Benefits

VA Benefits

Other: ________________________________________________________

Yes - Complete 6(d)

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

Yes - Complete 6(b) and (c)

Address

No - Go to 7

Telephone Number

( ___ ___ ___ )

___ ___ ___ – ___ ___ ___ ___

7. CRIMINAL OFFENSE/MISDEMEANOR 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?

Yes - Complete 7(a)-(f)

No - Go to 8

(a) What was/were 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 ll - INFORMATION ABOUT ANNUITANT
DATE CONTACTED:
1. ALL CUSTODY SITUATIONS
(a) Is the annuitant aware of entitlement to railroad retirement benefit?

Yes

No

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

Yes

No

(c) Did the annuitant receive funds?

Yes

No

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

Yes

No

(e) Does the annuitant have any unmet needs?

Yes - Explain in REMARKS

No

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

Yes - Go to 2

No

(g) Does the annuitant live alone?

Yes - Complete 2 and 3

No

Conclude
Interview

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

Yes - Indicate type of contact and enter frequency.

No - Explain why not.

Visits:

Telephone Calls:

Letters:

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

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

No

3. ANNUITANT LIVED ALONE
(a) Who was responsible for maintenance
expenses such as rent and utilities?

Annuitant

Payee

Other: ________________________________________

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

Annuitant

Payee

Other: _______________________________________

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

PART lll - INFORMATION FROM CUSTODIAN
DATE CONTACTED

CUSTODIAN’S NAME

ADDRESS

TELEPHONE NUMBER

( ___ ___ ___ )

___ ___ ___ – ___ ___ ___ ___

1. CUSTODIAN NOT THE PAYEE
(a) Did the annuitant live with the custodian
during the entire reporting period?

Yes - Go to 1(e)

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 lll (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?

Payee

Other:

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

Yes - Enter amount charged.
$

No

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

Yes - Indicate how.

No

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

Yes - Enter amount provided.
$

No

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

Yes

No

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

Yes

No

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

Yes

No

Explain in REMARKS

Visited - How frequently?

Provided clothing

Other:

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 form. 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 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, 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 lV – 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 benefits by the RRB, I affirm that to the best of my knowledge, the information 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