3220-0169

OMB NO. 3220-0169

Justification

Repayment of Debt

Form G-421F

1. Circumstances of information collection - Section 2 of the Railroad Retirement Act (RRA) (45 USC 231a) provides for payment of annuities to railroad employees who are retired due to age or disability and annuities or benefits to their eligible spouses, divorced spouses, and survivors.

Section 2 of the Railroad Unemployment Insurance Act (RUIA) (45 USC 352) provides for the payment of benefits to qualified railroad employees who are unemployed, but willing and able to work, and railroad employees who are unable to work due to sickness or injury.

When an overpayment of RRA or RUIA benefits has occurred, prompt action is initiated to notify the annuitant or beneficiary of the overpayment and the method by which the debt may be liquidated. The overpayment recovery methods available are cash refund by check, money order, credit card and withholding of annuities or benefits due.

Railroad Retirement Board (RRB) procedures pertaining to RRA annuity and benefit overpayment determinations and recovery are prescribed in 20 CFR Part 255. RUIA procedures pertaining to benefit overpayment determinations are prescribed in 20 CFR Part 340.

2. Purposes of collecting/consequences of not collecting the information - The customary options for repaying a debt have been by personal check and money order. In 1989, the RRB included the option of debt repayment by credit card.

Form G-421F, Repayment by Credit Card, is used by the RRB to obtain the information needed for repayment of a debt by credit card.

When a debt is owed on an RRA or RUIA-related debt, the RRB mails Form DRL-145, Debt Notice, to the debtor; a Form G-421, Repayment Method Form, for the debtor to indicate how they will repay the debt; a Form G-66 or G-66B, Your Rights to Review and/or Waiver, which explains what they can do if they disagree with the amount of the debt; and a Form G‑66A or G‑66BA, Rights Request Form, to request their right to have us review and/or waiver the debt. When the debtor does not respond to the initial debt notice, RRB Debt Recovery staff release Form G‑421F along with any one of a series of notices, such as the DR-422A or DR-422B, Response to Debt Notice Form. Forms G‑421, DR‑422A, and DR-422B each provide repayment options of check, money order, and credit card. Form G-421F is only completed and returned when the debtor selects the credit card repayment option.

The RRB prefills the identifying information at the top of the G-421F. The respondent completes the credit card authorization portion to designate which of the four types of authorized credit cards is being used, supplies the credit card number and expiration date, then signs and dates the form.

A pre-addressed envelope is furnished for returning the Repayment Method Form and Form G-421F, if the credit card option is selected. Upon receipt, an RRB Debt Recovery Specialist enters the information into the Pay.gov system for processing.

Completion of Form G-421F is voluntary.

This form is similar to the SSA-714, You Can Make Your Payment by Credit Card.

The RRB proposes no changes to Form G‑421F.

3. Planned use of improved information technology or technical/legal impediments to further burden reduction - Not cost effective because of low volume.

4. Efforts to identify duplication - This information collection does not duplicate any other information collection.

5. Small business respondents ‑ N.A.

6. Consequences of less frequent collection - Less frequent collection of the information would adversely affect recovery of amounts owed to the RRB due to benefit overpayments under the RRA and RUIA.

7. Special Circumstances - None

8. Public comments/consultations outside the agency - In accordance with 5 CFR 1320.8(d), comments were invited from the public regarding the information collection. The notice to the public was published on page 28907 of the May 10, 2016, Federal Register. No requests for information or comments were received. RRB personnel consult with Department of Treasury (Financial Management Service).

9. Payments or Gifts to Respondents - N.A.

10. Confidentiality – Privacy Act System of Record, RRB-21, Railroad Unemployment and Sickness Insurance Benefit System, and RRB-22, Railroad Retirement Survivor and Pensioner Benefit System. A Privacy Threshold Analysis for this collection has been completed by the RRB’s Chief Privacy Officer. There is no requirement for a Privacy Impact Analysis as this is a paper-based form. Electronic processing is through Pay.gov, which is a U.S. Treasury IT System.

11. Sensitive questions - There are no questions of a sensitive nature.

12. Estimate of respondent burden - The current estimated burden for this collection is unchanged as follows:

Current Burden

Form Number	Annual Responses	Time (Minutes)	Burden (Hours)
Form G-421f (RRA) activity	360	5	30
Form G-421f (RUIA) activity	175	5	15
Total	535		45

13. Estimate of annual cost to respondents or record keepers - N.A.

14. Estimated cost to Federal Government ‑ N.A.

15. Explanation for change in burden – N.A.

16. Time schedule for data collections and publications - The results of this collection will not be published.

17. Request not to display OMB expiration date - The G-421f is seldom revised. Given the costs associated with redrafting and distributing the form in order to keep the appropriate OMB expiration date in place, the RRB requests authorization to not display the expiration date on the form.

18. Exceptions to Certification Statement - None

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