G-99D (04-17) Parental Custody Report

Form Approved
OMB No. 3220-0176

UNITED STATES OF AMERICA

RAILROAD RETIREMENT BOARD

CURRENT

OFFICE HOURS: M-T-TH-F 9:00 AM TO 3:30 PM
WEDS. 9:00 AM TO 12:00 PM - CLOSED FEDERAL HOLIDAYS

TOLL-FREE NUMBER: 1-877-772-5772

RRB Claim No.:
Annuitant’s Name:
IMPORTANT:

Complete and return this form in the enclosed envelope within 15 days.
Read the Paperwork Reduction Act and Privacy Act Notices on the next page.
CHECK OR ENTER THE CORRECT ANSWER

1. Does the child live with you on a fulltime basis?



2. Provide the nearest estimate of the
percentage of time that the child
lives with you.



Yes - Go to Item 6
No - Complete Items 2, 3, 4, 5, and 6
75% (3 weeks per month)
50% (2 weeks per month)
Less than 50% (less than 2 weeks per
month)

3. Provide the name, address, and daytime telephone number of your child’s residence.
Name:
Address:
City, State, and ZIP Code:
Daytime Telephone Number:

(

4. How often do you visit your child?

)
Daily
Holiday

Weekly
Yearly

Monthly
Other - _____________

5. Who is responsible for making
decisions regarding the child?
6. Certification – I understand that failure to report or the making of a false or fraudulent report can
result in criminal prosecution or civil penalties, or both.
Signature

Date

Relationship to Annuitant or Title

(

)

Daytime Telephone Number
United States Railroad Retirement Board

Use enclosed envelope to return
this form to the address shown at
left. Fold properly (right above
Item 5) so address appears in
envelope window.
G-99D (04-17)

UNITED STATES RAILROAD RETIREMENT BOARD - 2
Paperwork Reduction Act and Privacy Act Notices
This notice is given under the Paperwork Reduction Act of 1995 and the Privacy Act of 1974. The
information requested on this form is used by the Railroad Retirement Board (RRB) to conduct a
review of your performance as representative payee. The RRB’s authority for requesting this
information is section 7(b)(6) of the Railroad Retirement Act of 1974.
Your obligation to provide the requested information is voluntary. However, your failure to respond
can result in you being asked to complete a more detailed report and it may result in a suspension
of benefit payments or, ultimately, your removal as representative payee.
The information you provide on this form may be disclosed without your approval to the individual
or institution you identified in Item 3. Such information may also be disclosed without your
approval to the Government Accountability Office for audits, to the Justice Department for
collecting overpayments owed to the RRB or the Social Security Administration, to law
enforcement agencies and in court proceedings.
A complete listing of the persons, organizations, and agencies to which the information you give us
may be released is available at any office of the RRB, if you wish to see it.
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 North Rush Street, Chicago Illinois 60611-1275.

G-99D (04-17)