Repayment by Credit Card

Repayment of Debt

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0169 can be found here:

Documents and Forms

Document Name Document Type
Form G-421F (07-16) Repayment by Credit Card Form
G-421F (07-16) Repayment by Credit Card Form G-421F (07-16).pdf Form
G-421F (12-17) Repayment by Debit Card Form G-421F (12-17).pdf Form

Information Collection (IC) Details

IC Title:	Repayment by Credit Card	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 255

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	G-421F (07-16)	Repayment by Credit Card	Form G-421F (07-16).pdf		No		Paper Only
Form	G-421F (12-17)	Repayment by Debit Card	Form G-421F (12-17).pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: RRB- 21, Railroad Retirement Survivor and Pensioner Benefit System	FR Citation: 79 FR 58874

Number of Respondents: 360	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	360	360
Annual IC Time Burden (Hours)	30	30
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.