G-421F (proposed) Repayment By Credit Card

PROPOSED

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0169

REPAYMENT BY CREDIT CARD
**Choose One**
Bill Doc ID

Beneficiary Name; Employee Name;
Claimant Name; Annuitant Name; Debtor Name

Amount of Overpayment

Either fill in all the information requested below and return this form in the enclosed envelope or pay the RRB
debt online through https://secure.rrb.gov/onlinebillpayment.
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

______/______

Amount Charged

$ ______________________________

Month

Year

By signing this form, you are authorizing the Railroad Retirement Board to process the request as
completed above.

Credit Card Holder’s Signature

Date Signed

Paperwork Reduction Act and Privacy 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 (xx-xx)