G-66a

CURRENT
RIGHTS REQUEST FORM

Billing Document Number:
Overpayment Amount:
Letter Date:
Employee's Name:
Your Name:
Full Address:
Daytime Phone:
(Please enter any missing information or correct any errors.)
YOUR REQUEST CHOICES (Place an "X" opposite your request choice)
____

REVIEW OF THE FACTS ONLY – (1)

____

WAIVER ONLY – (3)
(Waiver requests made at any time will be accepted. However, if the request is not received
within 60 days, any amounts collected prior to the request will not be waived.)

____

BOTH REVIEW OF THE FACTS AND WAIVER – (2)

____

PERSONAL CONFERENCE
(If you wish to request a personal conference, you must also make a request for a review of
the facts and/or waiver.)

Your remarks: (Use the back of this form if necessary.)

If you wish to request your rights, sign this form and return it in the enclosed self-addressed return envelope to:
Railroad Retirement Board
Retirement Survivor Debt Collections
PO Box 979018
St. Louis MO 63197-9000
Your Signature:

Date Signed:
For RRB Use Only: {

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G-66A (05-08)