DR-423 (04-17) Financial Disclosure Statement

CURRENT

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

FORM APPROVED
O.M.B. No. 3220-0127

FINANCIAL DISCLOSURE STATEMENT
GENERAL INSTRUCTIONS
Note: Before completing this form, you are advised to read the
PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICES on page 7 of this form.
Type or print all answers in ink. If you need more space
than is provided to answer a question, use Section 9 for
this purpose. If you do not know the answer to a question,
print “unknown” in the space provided for the answer.
Some items in the statement will not apply to you so you
will not need to answer them. Based on your answer to
a question, you may be told to skip to another item number or even another section. Follow the instructions that
tell you to “go to” another item. These are designed to
save you time and help you move through the statement
quickly, filling in only necessary information. If no “go to”
instructions are given, answer the next item in order. Do not
skip any items unless directed to do so.
If you are completing this form on behalf of an overpaid
annuitant or claimant, you must answer each question as
it applies to such annuitant or claimant.

We estimate that this form takes an average of 85 minutes
(1 hour and 25 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, IL 60611-1275.
Return the completed form in the envelope provided to
you by the Railroad Retirement Board office handling
your case.

For RRB Use Only Billing Document Number

SECTION 1 - PERSONAL DATA
Complete items 1 through 5 in all cases.

1 RAILROAD EMPLOYEE’S NAME
2 YOUR NAME
3 YOUR STREET ADDRESS
4 YOUR CITY, STATE AND ZIP CODE
5 YOUR DAYTIME TELEPHONE NUMBER (include area code)



Complete items 6 and 7 only if you are currently married, or were previously married and your former
spouse receives benefits from the Railroad Retirement Board. If otherwise, go to item 8.

6 YOUR SPOUSE’S NAME
7 YOUR SPOUSE’S AGE
Form DR-423 (04-17) Page 1 (DESTROY PRIOR EDITIONS)

Complete item 8 only if you claim to support dependents. This includes relatives living in the same household
or any individuals whom you have legal obligation to support that are living in the same household. Otherwise,
go to item 9.

8 NAME(S) AND AGE(S) OF YOUR DEPENDENT(S)
NAME OF DEPENDENT

AGE

RELATIONSHIP TO YOU

a
b
c
d
e

SECTION 2 - EMPLOYMENT INFORMATION
Complete item 9 only if you, your spouse or dependents are currently employed. Otherwise, go to Section 3.

9

NAME OF EMPLOYED INDIVIDUAL

NAME AND ADDRESS

OF

EMPLOYER

a
b
c
d

SECTION 3 - MONTHLY INCOME

SECTION 4 - MONTHLY HOUSEHOLD EXPENSES

Complete this section entering the amount of all monthly
income you receive. Include the income of your spouse
and the income of all dependents you are supporting.
Your spouse’s income should be entered without regard
to dependency.

Complete this section entering the amount of all monthly
expenses. Include the expenses of your spouse and the
expenses of all dependents you are supporting.

If you cannot allocate certain income on a month by
month basis and a yearly amount is available, please
divide the yearly amount by twelve and enter the result
as the monthly amount.

If you cannot allocate certain expenses on a month by
month basis and a yearly amount is available, please
divide the yearly amount by twelve and enter the result
as the monthly amount. Avoid duplication of entries.
Electricity and heat should be the monthly average
based on the past twelve months.

If you need additional space for entries or explanations,
use the remarks area in Section 9. If an answer is zero,
enter “0.”

If you need additional space for entries or explanations,
use the remarks area in Section 9. If an answer is zero,
enter “0.”

Form DR-423 (04-17) Page 2

10

YOU

MONTHLY INCOME

YOUR
SPOUSE

11

MONTHLY HOUSEHOLD EXPENSES

a

AVERAGE EARNINGS FROM
EMPLOYMENT OR SELF-EMPLOYMENT

a

RENT OR MORTGAGE (include any
property taxes in this amount)

b

RAILROAD RETIREMENT

b

FOOD

c

SOCIAL SECURITY

c

ELECTRICITY (average for the past 12
months)

d

OTHER BENEFITS (civil service, VA,
private pension, insurance, blacklung,
unemployment, SSI)

d

HEAT (average for the past
12 months)

e

WELFARE (local welfare or
public assistance)

e

TELEPHONE

f

OTHER INCOME (rentals, dividends,
interest, IRA distributions)

f

TRANSPORTATION (gasoline, oil,
carfare, taxi, etc.)

g

CONTRIBUTIONS FROM RELATIVES

g

INSURANCE (include health, life,
auto, home, renter’s)

h

TOTAL MONTHLY INCOME
(add lines 10a - 10g)

i

COMBINED MONTHLY INCOME OF YOU
AND YOUR SPOUSE (add both amounts
on line 10h)

h

CLOTHING

j

INCOME OF DEPENDENTS OTHER THAN
YOUR SPOUSE (income for those listed

i

MEDICAL AND DENTAL (prescriptions
and other medicines not paid for by
your health insurance)

j

OTHER LIVING EXPENSES (specify in
remarks)

k

TOTAL MONTHLY HOUSEHOLD
EXPENSES (total of lines 11a - 11j)

in item 8)

k

TOTAL MONTHLY FAMILY INCOME (total
of lines 10i and 10j)

SELF AND ALL
DEPENDENTS

SECTION 5 - SUMMARY OF DEBTS
List the details of all outstanding balances for which you presently make monthly payments. Items
14a, b and c are all debts other than those which have been entered elsewhere on this financial
statement (such as medical bills, construction bills, car payments, etc.). If you do not know the exact
balance, estimate the balance. If an answer is zero, enter “0.”

12 OUTSTANDING MORTGAGE BALANCE

13 DELINQUENT TAXES

Form DR-423 (04-17) Page 3

DETAILS OF OTHER DEBTS
DATE DEBT
INCURRED

14 NAME OF CREDITOR

PURPOSE OF
DEBT

ORIGINAL
AMOUNT

UNPAID
BALANCE

a
b
c
d TOTAL UNPAID BALANCE (add lines 14a - 14c)
e TOTAL MONTHLY PAYMENTS (add lines 14a - 14c)
f TOTAL MONTHLY HOUSEHOLD EXPENSES (from item 11k, Section 4)
g TOTAL MONTHLY EXPENSES (add lines 14e and 14f)

SECTION 6 - BALANCE SUMMARY
Enter the amount as shown in the items previously completed. If an answer is zero, enter “0.”

15 TOTAL MONTHLY FAMILY INCOME (from item 10k, Section 3)
16 TOTAL MONTHLY EXPENSES (from item 14g, Section 5)
17 BALANCE (subtract line 16 from line 15)
18 HOW MUCH OF THE BALANCE ON LINE 17 CAN YOU APPLY MONTHLY TO
YOUR DEBT TO THE RAILROAD RETIREMENT BOARD?

19 IF YOUR TOTAL MONTHLY EXPENSES EXCEED INCOME, HOW DO YOU PAY THE
DIFFERENCE? USE

SECTION 9 TO CONTINUE YOUR EXPLANATION IF NECESSARY.

Form DR-423 (04-17) Page 4

MONTHLY
PAYMENT

SECTION 7 - SUMMARY OF ASSETS
List the current value of all assets presently owned individually or in joint tenancy. Give resale value of
automobiles, etc. If you do not know the exact value, estimate the value. If an answer is zero, enter “0.”

20a CASH IN BANK OR OTHER

g CASH VALUE OF LIFE INSURANCE

FINANCIAL INSTITUTIONS

(checking and savings)

h STOCKS AND OTHER BONDS

b CASH ON HAND

i VALUE OF HOME

c AUTOMOBILES (resale value)

j VALUE OF OTHER REAL ESTATE

d RECREATIONAL VEHICLES (resale value)

ASSETS (attach list or explain
k OinTHER
Section 9)

e CERTIFICATES OF DEPOSIT

l TOTAL

ASSETS (add lines 20a — 20k)

f U.S. SAVINGS BONDS

SECTION 8 - ADDITIONAL FINANCIAL INFORMATION
21

HAVE YOU BEEN DECLARED BANKRUPT DURING
THE PAST SEVEN YEARS?

22

23



YES (if yes, complete date discharged and
court location)



NO

DATE
DISCHARGED

COURT LOCATION

HAVE YOU FILED A FEDERAL INCOME TAX RETURN WITHIN THE LAST TWO YEARS?



YES (if yes, you must furnish a copy of your latest return)



NO (if no, state the year in which you last filed a return)

HAVE YOU TRANSFERRED OWNERSHIP OF ANY PROPERTY (TANGIBLE OR INTANGIBLE) WITHIN THE LAST TWO YEARS?
EXAMPLES OF SUCH PROPERTY WOULD INCLUDE CASH, SAVINGS, JEWELRY, BONDS, STOCKS, REAL ESTATE, ETC.



YES (if yes, you must list all transferred property and its approximate value in Section 9)



NO

Form DR-423 (04-17) Page 5

SECTION 9 - REMARKS
24

This section is to be used for the continuation of answers to other items. Be sure to include the item number at the
beginning of the answer you wish to continue. You may also use this section to enter any additional information that
you feel may be important to include. if you need more space, attach additional sheets.

IF YOU NEED MORE SPACE, ATTACH ADDITIONAL SHEETS

CERTIFICATION
I (we) affirm that the information contained herein is
correct and complete to the best of my (our) knowledge.
I (we) know that if I (we) make a false or fraudulent
statement in order to receive benefits from the Railroad
Retirement Board or that if I (we), through my (our)

action or non-action, induce the Railroad Retirement
Board to pay me (us) benefits to which I am (we are)
not otherwise entitled, I am (we are) committing a crime
which is punishable under Federal law by fine or by
imprisonment or both.

YOUR SIGNATURE

DATE

YOUR SPOUSE’S SIGNATURE

DATE

If you and/or your spouse signed this statement by mark (“X”), two witnesses who know you must sign
below giving their full address.
SIGNATURE OF WITNESS

Address (number and street)
City, state and ZIP code
Telephone number (include area code)

SIGNATURE OF WITNESS



(

)



(

)

Address (number and street)
City, state and ZIP code
Telephone number (include area code)

Form DR-423 (04-17) Page 6

PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICES

The Railroad Retirement Board (RRB) is
authorized to collect the above information under section 7b(6) of the Railroad
Retirement Act and under section 12(l) of
the Railroad Unemployment Insurance Act.
If an overpayment of benefits has been
made to you, this information will enable
the RRB to determine whether it can
waive its right to recover such overpayment. The RRB can waive its right to
recovery only when you are not at fault
in connection with the overpayment and
recovery would deprive you of income
needed to meet ordinary living expenses
or would otherwise be unfair. Otherwise,
the RRB is required by law to recover any overpayment. Moreover, if the
RRB determines that recovery may not
be waived, the financial information
obtained on this form may then be important in establishing the rate of recovery
or the extent of the recovery efforts.
You are not required to provide the information on this form; however, your failure to provide the requested information may result in a denial of your waiver request and, if the RRB is unable to
recover the overpayment, it may be necessary to report the overpayment to another
Federal agency or to a private collection
agency for further collection effort.

The RRB may disclose specific information or records relating to your waiver
request to certain third parties without
your prior written consent or the prior
written consent of the person to whom
the information or record applies. The
routine uses or disclosures which may
be made of information from this form
include the following:








Information or records may be
disclosed to any last employer to
verify statement(s) of earnings.
Information or records may be
disclosed to the Government
Accountability Office for auditing of debts arising from overpayments under either the
Railroad Retirement or Social
Security Acts.
Information or records may be
disclosed in a court proceeding
relating to a decision with respect
to your request for a waiver.
Information or records may be
disclosed in certain instances
for law enforcement purposes to
the appropriate Federal, state or
local enforcement agency.

The RRB’s current list of routine uses may be inspected at any office of the RRB.
Form DR-423 (04-17) Page 7