Transmittal Letter for Form G-106

UNITED STATES OF AMERICA

RAILROAD RETIREMENT BOARD

PROPOSED

WWW.RRB.GOV
OFFICE HOURS: M-T-TH-F 9:00 AM TO 3:30 PM
WEDS. 9:00 AM TO 12:00 PM - CLOSED FEDERAL HOLIDAYS

TOLL-FREE NUMBER: 1-877-772-5772

,
In reply refer to
Annuitant Name:
Rep Payee Name:
RRB Claim Number:
We are monitoring the care and responsibility of the annuitant named above and our records
indicate that the annuitant resides with you. Since the representative payee does not have custody
of the annuitant, we need your assistance in providing specific information on the annuitant’s wellbeing. Please complete the form on the next page and return to us within 15 days from the date of
this letter. If you have any questions about this form, write to us at the address shown above or
telephone us at our toll-free number. For general information about railroad retirement benefits,
visit our website at www.rrb.gov.
Paperwork Reduction Act and Privacy Act Notices - The information requested on this form is
needed to determine if the applicant is eligible to continue receiving benefits from the RRB. The
RRB’s authority for requesting this information is section 7(b)(6) (45 U.S.C. 231f(b)(6)) of the
Railroad Retirement Act. Although you are not required to provide this information, if you fail to do
so, we may not be able to ensure that benefits are correctly being used for the annuitant.
We estimate this form takes an average of 10 minutes per response to complete, including the time
for reviewing the instructions, getting the needed data, and reviewing the completed form. Federal
agencies may not conduct or sponsor, and respondents are not required to respond to a collection
of information unless it displays a valid OMB number. If you wish, send comments regarding the
accuracy of our estimate or any other aspect of this form, including suggestions for reducing
completion time, to Associate Chief Information Officer for Policy and Compliance, Railroad
Retirement Board, 844 N. Rush Street, Chicago, Illinois 60611-1275.
Return Instructions
Please use the enclosed envelope to return the form to our office located at .

Enclosures
Form G-106
Envelope

RL-106 (xx-xx)