G-421 (04-08)

CURRENT
REPAYMENT METHOD
Overpayment Amount: $000.00

Letter Date: MM/dd/yyyy

Please place an "X" opposite the method you choose for repayment and sign this form. Use the
self-addressed envelope and return this form to the address below. However, if you wish to
make alternative arrangements to repay your debt, please contact one of our collection
specialists at (312) 751-4630.
Railroad Retirement Board
Retirement Survivor Debt Collections
PO Box 979018
St. Louis MO 63197-9000
REPAYMENT CHOICES
Repayment in full by personal check or money order — (1)
You can repay the overpayment by sending a check or money order, for the full
amount, payable to the Railroad Retirement Board. Be sure to include your name and the
Billing Document Number shown at the bottom of this page, on the check or money order.
If you send us a check, it will be converted into an electronic funds transfer (EFT). This
means we will copy your check and use the account information on it to electronically debit
your account for the amount of the check. The debit from your account will usually occur
within 24 hours, and will be shown on your regular account statement.
You will not receive your original check back. We will destroy your original check, but we
will keep the copy of it. If the EFT cannot be processed for technical reasons, you
authorize us to process the copy in place of your original check. If the EFT cannot be
completed because of insufficient funds, we may try to make the transfer up to 2 times.
Credit Card — (2)
You can repay the overpayment by charging the full amount to your VISA, MasterCard,
Discover Card, or American Express card.
You must complete the enclosed Form G-421F, Repayment by Credit Card Form.
IMPORTANT REMINDER
Prefill 1
If this form is not returned to the Railroad Retirement Board within 30 days from the date of the enclosed
overpayment letter, and you have not requested a waiver or review of the facts, interest will begin to accrue on the
unpaid portion of this debt. A penalty will begin to accrue on any amounts unpaid after 120 days from the date of the
overpayment letter. Administrative costs may be added to any delinquent debt amount.
Prefill 2
If this form is not returned to the Railroad Retirement Board within 60 days from the date of the enclosed
overpayment letter and you have neither appealed the reconsideration decision nor contacted one of our collection
specialists, your annuity will be suspended for the length of time necessary to completely recover the overpayment,
as explained in our reconsideration decision. Administrative costs may be added to any delinquent debt amount.
Prefill 3
If this form is not returned to the Railroad Retirement Board within 30 days from the date of the enclosed
overpayment letter and you have not appealed the reconsideration decision, interest will begin to accrue on the
unpaid portion of this debt. A penalty will begin to accrue on any amounts unpaid after 120 days from the date of the
overpayment letter. Administrative costs may be added to any delinquent debt amount.

Signature

Date Signed

You may pay this debt online at WWW.RRB.GOV under Benefit Online Services.
Billing Document Number: B2- {xxxxxxxxx}
G-421 (04-08)