G-99 (Proposed) Parental Custody Report

Proposed

Form Approved OMB No. 3220-0176

United States of America

Railroad Retirement Board

Office of Programs/Policy & Systems

844 North Rush Street

Chicago, IL 60611-1275

Office Number: 1-312-469-2135

WWW.RRB.GOV

     

     

     

     

, 

January 16, 2024

     

     

     

     

RRB Claim No.:      

Annuitant’s Name:      

Reporting Period:

Office Hours:

9:00 AM to 3:00 PM MONDAY THROUGH FRIDAY EXCEPT FEDERAL HOLIDAYS

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

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
Provide 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)
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?

5. Enter the total amount of railroad retirement benefits

received for the child during the reporting period.

5. Enter the dollar amount of railroad retirement benefits

used for the child during the reporting period.

5. Describe how the railroad retirement benefits were used for the child during the reporting period.

5. 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.

5. 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

United States Railroad Retirement Board Office of Programs/Policy & Systems 844 North Rush Street Chicago, IL 60611-1275

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.

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 15 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 (04-22)

Stephanie Swilley