DR-422c (07-08)

CURRENT
Response to Debt Notice
Name:
Billing Document No.:
Overpayment Amount:
Letter Date:
Below are the repayment methods available to you.
Please indicate the repayment method you are choosing. Sign and date this form. Return this
form, along with your check, money order or completed Form G-421F, Repayment by Credit
Card, in the pre-addressed envelope we have provided.
Payment in full by check or money order — (1)
I am paying the amount by check or money order. The check or money order should be
made payable to the Railroad Retirement Board. The Billing Document Number should be
shown on the front of your 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
Payment in full by credit card — (2)
I am authorizing a charge to my VISA, MasterCard, DISCOVER or American Express.
You must complete the enclosed Form G-421F, Repayment by Credit Card.

Payment by partial withholding — (4)
I am not able to pay the full amount at this time. I would like $_______________ withheld
from my monthly Railroad Retirement Annuity until my debt is recovered in full.

Signature: _________________________________ Date Signed:
If you have any questions regarding repayment of this debt, you may contact us directly at (312)
751. A debt recovery specialist is available each business day. When you call, you will
be asked to provide the Billing Document Number shown at the top of this form.
You may pay this debt online at www.rrb.gov under Benefit Online Services.

DR-422C (07-08)