G-99 (Proposed) Parental Custody Report

Form Approved
OMB No. 3220-0176

UNITED STATES OF AMERICA

RAILROAD RETIREMENT BOARD
BIS - POLICY & COMPLIANCE
844 NORTH RUSH STREET

PROPOSED

CHICAGO, IL 60611-1275
WWW.RRB.GOV
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.:
Child’s Name:
Reporting Period:
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 full
time basis?

Yes - Go to Item 6
No - Complete Items 2, 3, 4, 5, and 6

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

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

Weekly

Monthly

Holiday

Yearly

Other 5. Who is responsible for making
decisions regarding the child?
6. Enter the total amount of railroad retirement benefits
received for the child during the reporting period.
7. Enter the dollar amount of railroad retirement benefits
used for the child during the reporting period.
8. Describe how the railroad retirement benefits were used for the child during the reporting period.

G-99D (xx-xx)

UNITED STATES RAILROAD RETIREMENT BOARD - 2
9. If there were surplus railroad retirement benefits at the end of the reporting period, enter how the
balance was held.
Cash: $
Checking Account: $ __
Savings Account: $
Other: $
Describe:
NOTE: If surplus benefits were held in checking or savings accounts, enter the title or
ownership registration of the account below.

10. 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 Child or Title

(

)

Daytime Telephone Number
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.

United States Railroad Retirement Board
BIS - Policy & Compliance
844 North Rush Street
Chicago, IL 60611-1275

Use enclosed envelope to return this
form to the address shown at left.
Refold properly so address appears in
envelope window.

G-99D (xx-xx)