3220-0151

OMB NO. 3220-0151

Justification

Representative Payee Monitoring

RRB Form G-99a, G-99c, and G-106

1. Circumstances of information collection - Under Section 12 of the Railroad Retirement Act (RRA), the Railroad Retirement Board (RRB) may pay annuity benefits to a representative payee when an employee, spouse, or survivor annuitant is incompetent or a minor. The RRB periodically requires representative payees to account for the use of benefits received on behalf of the beneficiary. The procedures pertaining to the appointment and responsibilities of a representative payee and the accountability requirement authorizing the RRB to conduct periodic monitoring of representative payees, including a written accounting of benefit payments received, are prescribed in 20 CFR 266.

2. Purposes of collecting/consequences of not collecting the information - The RRB uses the following forms to conduct an on-going representative payee monitoring program.

Form G-99a, Representative Payee Report, is used by the RRB to obtain information needed to determine whether the benefit payments certified to the representative payee have been used for the annuitant's current maintenance and personal needs, and whether the representative payee continues to be concerned with the annuitant's welfare. The form is computer-generated and released from RRB headquarters directly to the representative payee, along with an envelope for returning the completed form to the RRB office shown in the lower portion of the form. Release of the G-99a is triggered by information stored in the RRB's Checkwriting Integrated Computer Operation (CHICO) file. The identifying information and the reporting period beginning and ending dates in the upper portion of the form are computer printed by the RRB before the form is released. Form G-99a, also contains the Paperwork Reduction Act/Privacy Act Notices and a listing of representative payee duties. At the time of appointment, the RRB furnishes each representative payee an informational booklet, RB-5, Your Duties As Representative Payee (OMB approved 3220-0052). The RB‑5 contains an account book that the RRB recommends the representative payee use for maintaining a record of his or her use of railroad retirement benefits on behalf of an annuitant.

The RRB office is responsible for controlling the return of the completed G-99a within the 15‑day time period prescribed on the form. If the initial G-99a is not returned within the prescribed 15-day period, a follow-up G-99a is released by the RRB office. If the follow-up G‑99a is not returned within 15 days, the RRB office schedules an interview with the representative payee to obtain more detailed information.

The RRB proposes no changes to Form G-99a.

Form G-99a is similar to Form SSA-623-F6, Representative Payee Report, OMB No. 0960‑0068.

Form G-99c, Representative Payee Evaluation Report, is used by an RRB office to obtain more detailed information from a representative payee who fails to complete and return a Form G-99a, or in situations when the returned Form G-99a indicates the possible misuse of funds by the representative payee. Form G-99c contains specific questions concerning the representative payee's performance, and is used by the RRB to determine whether or not the representative payee should continue in that capacity.

Form G-99c is a three-part form completed by the RRB based on information provided during an interview with a representative payee (Part I), the annuitant (Part II), and the custodian of the annuitant, if any (Part III). Options for conducting the interview include:

• at an RRB office,

• by telephone,

• at an itinerant point, or

• at the annuitant's residence.

The identifying information above Part I of the form is entered by the RRB representative prior to the interview with the representative payee. After furnishing the information requested on Form G-99c, the representative payee and custodian (if any) are required to sign the Form G‑99c and are advised of the penalties resulting from fraudulent statements or for withholding information to misrepresent a fact material to determining a right to a payment under the Railroad Retirement Act.

The RRB proposes no changes to Form G-99C.

Form G-99c is similar to Form SSA-624-F5, Representative Payee Evaluation Report, OMB No. 0960-0069.

In addition to the required review under the Paperwork Reduction Act, Form G-106 was reviewed by staff from the RRB’s Office of General Counsel (OGC) and Office of the Inspector General (OIG). The OGC advised that the form was legally acceptable. Subsequently, the form has been reviewed and endorsed for use (pending OMB approval) by the RRB’s Board Members.

New Form G-106, Statement of Care and Responsibility to Annuitant, will be used in cases where the representative payee does not have custody of the annuitant, to solicit information about the representative payee’s performance and the annuitant’s well-being from the custodian of the annuitant. The proposed form contains specific questions concerning the representative payee's performance, and will be used by the RRB to determine whether or not the representative payee should continue in that capacity.

Form G-106 will be computer-generated and released directly to the custodian by RRB Headquarters via proposed transmittal letter Form RL-106, along with an envelope for returning the completed form to the appropriate RRB office. Release of the G-106 will be triggered by a schedule of follow-up contacts to all third-party custodians of annuitants with representative payees. Identifying information will be printed by the RRB on the form before it is released. The Paperwork Reduction Act and Privacy Act Notices are on the RL-106 transmittal letter.

Proposed Form G-106 is similar to Form SSA-788, Statement of Care and Responsibility for Beneficiary, OMB No. 0960-0109.

3. Planned use of improved information technology or technical/legal impediments to further burden reduction - None at present time. Forms are initiated by RRB with prefilled data.

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

5. Small business respondents - N.A.

6. Consequences of less frequent collection - Each payee reports on a triennial basis. Less frequent reporting would not be advisable considering the circumstances.

7. Special Circumstances - None

8. 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 19396 of the April 27, 2017, Federal Register. No comments or requests for additional information were received.

9. Payments or gifts to respondent - None

10. Confidentiality - Privacy Act System of Records, RRB-22, Railroad Retirement Survivor and Pensioner Benefit System. In accordance with OMB Circular M-03-22, a Privacy Impact Assessment for this information collection was completed and can be found at

https://www.rrb.gov/sites/default/files/2017-06/PIA-BPO.pdf.

11. Sensitive questions - N.A.

12. Estimate of respondent burden - The estimated annual burden for the information collection is unchanged as follows:

Current Burden

Form Number	Annual Responses	Time (Minutes)	Burden (Hours)
G-99a (legal and all other, excepting parent for child)	5,400	18	1,620
G-99c (Parts I and II)	300	24	120
G-99c (Parts I, II, and III)	120	31	62
Total	5,820		1,802

Proposed Burden

Form Number	Annual Responses	Time (Minutes)	Burden (Hours)
G-99a (legal and all other, excepting parent for child)	5,400	18	1,620
G-99c (Parts I and II)	300	24	120
G-99c (Parts I, II, and III)	120	31	62
G-106	500	10	83
Total	6,320		1,885

Responses Hours

Total burden Change +500 +83

Program Change +500 +83

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

14. Estimate of cost to Federal Government - N.A.

15. Explanation for change in burden - The estimated overall responses for this collection have increased by 500, from 5,820 to 6,320 and the burden hours have increased by 83, from 1,802 to 1,885. This is due to the addition of new Form G-106. We have shown the +500 responses and +83 burden hours as a program change.

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

17. Request not to display OMB expiration date - Given the costs associated with redrafting, reprinting, and distributing the forms in this collection in order to keep the appropriate OMB expiration date in place, the RRB requests the authority to not display the OMB expiration date on the forms associated with this collection.

18. Exceptions to Certification Statement - None

-4-