Dr-422a (12-17)

CURRENT
Response to Debt Notice
Name:
Billing Document ID:
Overpayment Amount:
Letter Date:
You can either pay this overpayment online through https://secure.rrb.gov/onlinebillpayment or
you can indicate below, the repayment method you wish to use. Sign and date this form, and
return it in the pre-addressed envelope we have provided. If a payment is being included,
enclose your check or money order. The payment must be made in U.S. dollars and drawn on
a U.S. bank. If the payment is by debit card, enclose a completed Form G-421F, Repayment by
Debit Card.
I am paying the full amount by check or money order.
NOTE: The check or money order should be made payable to the Railroad Retirement
Board. Be sure to include your name and the Billing Document ID shown at the top of this
page, on the check or money order.
If you send us a check, it will be converted into an electronic funds transfer (EFT). This
means we will copy your check and use the account information on it to electronically debit
your account for the amount of the check. The debit from your account will usually occur
within 24 hours, and will be shown on your regular account statement.
You will not receive your original check back. We will destroy your original check, but we
will keep the copy of it. If the EFT cannot be processed for technical reasons, you
authorize us to process the copy in place of your original check. If the EFT cannot be
completed because of insufficient funds, we may try to make the transfer up to 2 times.

I am authorizing a payment of the full amount using my VISA, MasterCard, DISCOVER or
American Express debit card. (Credit cards are no longer acceptable.)
NOTE: You must complete the enclosed Form G-421F, Repayment by Debit Card.
If you have any questions regarding repayment of this overpayment, you may contact us directly
at (312) 751-*** LAST FOUR ***. A debt recovery specialist is available each business day.
When you call, you will be asked to provide the Billing Document ID shown at the top of this
form.

Signature: _________________________________ Date Signed:

DR-422A (12-17)