Form G-421F (04-10) G-421F (04-10) Repayment by Credit Card

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0169

CURRENT

REPAYMENT BY CREDIT CARD
**Choose Name**

Billing Document Number

Amount of Overpayment

If you choose to repay by credit card, please fill in all the information requested below and return this form in
the envelope we have provided. You may pay this debt online at www.rrb.gov under Benefit Online Services.
Credit Card Holder’s Name

First Name, Middle Initial, and Last Name

(As It Appears On The Credit Card)
Number and Street

Credit Card Holder’s Address
City, State, and ZIP Code

Daytime Telephone Number
Type of Credit Card

(__ __ __)
VISA

__ __ __ – __ __ __ __
MasterCard

DISCOVER

American Express

Credit Card Number

___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Credit Card Expiration Date

Month and Year ______/_______

Amount Charged

$ ______________________________

Credit Card Holder’s Signature

Date Signed

Privacy Act and Paperwork Reduction Act Notices
Our authority for requesting credit card information from you is sections 7(b)(1) and 7(b)(3) of the Railroad
Retirement Act and sections 12(a) and 12(l) of the Railroad Unemployment Insurance Act. If you select the
credit card repayment method, we will use the credit information to effect the repayment of the debt by
charging your credit card account. You are not required to furnish this information to us; however, if you select
the credit card method for repayment of your debt and fail to furnish this information, we will not be able to
effect repayment through this method.
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 N. Rush Street, Chicago, IL 60611-2092.
G-421F (04-10)