G-421 (04-13)

CURRENT
Overpayment Amount:

ALTERNATIVE REPAYMENT METHOD
Letter Date:

You can either pay this overpayment online through https://secure.rrb.gov/onlinebillpayment or
below, you can indicate the repayment method you wish to use. Sign and date this form, and
return it in the pre-addressed envelope we have provided. If a payment is being included,
enclose your check or money order. Checks and money orders must be drawn on a US bank,
in US dollars. If the payment is by credit card, enclose a completed Form G-421F, Repayment
by Credit Card. To make alternative arrangements to repay your overpayment, 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
ALTERNATIVE REPAYMENT CHOICES
Repayment in full by check or money order
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 ID 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
You can repay the overpayment by charging the full amount to your VISA, MasterCard,
DISCOVER or American Express.
NOTE: You must complete the enclosed Form G-421F, Repayment by Credit Card.
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
Billing Document ID: B2G-421 (04-13)