G-106 (Proposed) Statement of Care and Responsibility to Annuitant

United States of America
Railroad Retirement Board

Form Approved
OMB. No. 3220-0151

PROPOSED
Annuitant Name

Statement of Care and
Responsibility for Annuitant

Rep Payee Name
RRB Claim Number
Month

1.

Enter the date the annuitant began living with you.

2.

a. If the annuitant is not living with you, provide
the date the annuitant stopped living with you
and complete Item 2b.
Month

3.

a.

Day

Year

Do you believe the annuitant is now capable of managing or
directing the management of benefits in his or her best interest?
Yes – Go to Item 4
No – Go to Item 3b

Provide a brief explanation.

4.

How often does the representative payee visit the annuitant?

5.

a. Does the representative payee pay toward the annuitant’s care
and maintenance?
b. Enter how much the representative payee pays.
c. Indicate the frequency of the payments listed in Item 5b above.

6.

Year

b. Provide the name, address, and telephone
number of the person with whom the annuitant is
living.

By capable we mean the beneficiary:
 Is able to understand and act on the ordinary affairs of life,
such as providing food, housing, clothing, etc., and
 Is able, in spite of physical impairments, to manage funds
or direct others on how to manage them.
b.

Day

a. Does the annuitant have any unmet personal needs at this time?

________________________
Yes – Go to Item 5b
No – Go to Item 6

$
Monthly
Yearly
Other: _______________
Yes – Go to Item 6b
No – Go to Item 7

b. Enter any unmet personal needs.

Form G-106 (xx-xx)

United States of America
Railroad Retirement Board

Form Approved
OMB. No. 3220-0151

7.

a. Does the representative payee give you any instructions for the
annuitant’s care?
b. Explain what those instructions are.

Yes - Go to Item 7b
No - Go to Item 8

8.

a. Are there other relatives or friends who have provided support
and/or shown interest in the annuitant?

Yes - Go to Item 8b
No - Go to Item 9

b. Enter the name and relationship.
Name

9.

Relationship

Enter the name and telephone number of the person you would
contact in case of an emergency.
Name:

Area Code

Telephone Number

10.

Remarks
You may use this section if additional space is needed for explaining any answers to the questions.

11.

Certification Statement
I understand that civil and criminal penalties may be imposed on me for false or fraudulent statements
or for withholding information to cause payment of benefits by the RRB. I affirm that to the best of my
knowledge, the information I have given is true, complete, and correct.
Area Code
Telephone Number
Name and Telephone Number
Month

Signature and Date

Day

Year

Mailing Address (Number and Street, Apt. No., P.O. Box)

City

State

Page 2

ZIP Code

Form G-106 (xx-xx)