Repayment by Credit Card

Repayment of Debt

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0169 can be found here:

Documents and Forms

Document Name Document Type
Form G-421F (04-10) Repayment by Credit Card Form
G-421F (04-10) Repayment by Credit Card Form G-421F (04-10).pdf Form
G-421F (proposed) Repayment By Credit Card Form G-421F Proposed.pdf Form

Information Collection (IC) Details

IC Title:	Repayment by Credit Card	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 255

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	G-421F (04-10)	Repayment by Credit Card	Form G-421F (04-10).pdf		No		Paper Only
Form	G-421F (proposed)	Repayment By Credit Card	Form G-421F Proposed.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: RRB- 21, Railroad Retirement Survivor and Pensioner Benefit System	FR Citation: 75 FR 43727

Number of Respondents: 360	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	360	160	200
Annual IC Time Burden (Hours)	30	13	17
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.