G-421F (12-17) Repayment by Debit Card

United States of America
Railroad Retirement Board

CURRENT

Form Approved
OMB No. 3220-0169

REPAYMENT BY DEBIT CARD
*Choose One*

Bill Doc ID

Amount of Overpayment

Either fill in all the information requested below and return this form in the enclosed envelope or pay the RRB
debt online through https://secure.rrb.gov/onlinebillpayment.
Debit Card Holder’s Name

First Name, Middle Initial, and Last Name

(As It Appears On The Debit Card)
Number and Street

Debit Card Holder’s Address
City, State, and ZIP Code

Daytime Telephone Number
Type of Debit Card

(__ __ __)

__ __ __ – __ __ __ __

VISA

MasterCard

DISCOVER

American Express

Debit Card Number

___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Debit Card Expiration Date

______/______

Amount Charged

$ ______________________________

Month

Year

Security Code

_____________________

By signing this form, you are authorizing the Railroad Retirement Board to process the request as
completed above.

Debit Card Holder’s Signature

Date Signed

Paperwork Reduction Act and Privacy Act Notices
Our authority for requesting debit card information from you is sections 7(b)(1) and 7(b)(3) of the Railroad
Retirement Act and sections 12(a) and 12(l) of the Railroad Unemployment Insurance Act. If you select the
debit card repayment method, we will use the debit information to effect the repayment of the debt by charging
your debit card account. You are not required to furnish this information to us; however, if you select the debit
card method for repayment of your debt and fail to furnish this information, we will not be able to effect
repayment through this method.
We estimate this form takes an average of 5 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, IL 60611-1275.
G-421F (12-17)