G-66ba (03-13)

CURRENT
RIGHTS REQUEST FORM

Billing Document ID:
Overpayment Amount:
Letter Date:
Employee's Name:
Your Name:
Full Address:
Daytime Phone:
(Please enter any missing information or correct any errors.)
YOUR REQUEST CHOICES (Place an "X" opposite your request choice)
____

REVIEW OF THE FACTS ONLY

____

WAIVER ONLY
(Waiver requests made at any time will be accepted. However, if the request is not received
within 60 days, any amounts collected prior to the request will not be waived.)

____

BOTH REVIEW OF THE FACTS AND WAIVER

Your remarks: (Use the back of this form if necessary.)

If you wish to request your rights, sign this form and return it in the enclosed self-addressed return envelope to:
Railroad Retirement Board
Retirement Survivor Debt Collections
PO Box 979018
St. Louis MO 63197-9000
Your Signature:

Date Signed:
For RRB Use Only: {

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G-66BA (03-13)