# Agency Forms Submitted for OMB Review, Request for Comments
In accordance with the Paperwork Reduction Act of 1995 (44 U.S.C. Chapter 35), the Railroad Retirement Board (RRB) is forwarding an Information Collection Request (ICR) to the Office of Information and Regulatory Affairs (OIRA), Office of Management and Budget (OMB). Our ICR describes the information we seek to collect from the public. Review and approval by OIRA ensures that we impose appropriate paperwork burdens.
The RRB invites comments on the proposed collections of information to determine (1) the practical utility of the collections; (2) the accuracy of the estimated burden of the collections; (3) ways to enhance the quality, utility, and clarity of the information that is the subject of collection; and (4) ways to minimize the burden of collections on respondents, including the use of automated collection techniques or other forms of information technology. Comments to the RRB or OIRA must contain the OMB control number of the ICR. For proper consideration of your comments, it is best if the RRB and OIRA receive them within 30 days of the publication date.
*1. Title and purpose of information collection:* Supplemental Information on Accident and Insurance; OMB 3220-0036.
Under Section 12(o) of the Railroad Unemployment Insurance Act (RUIA) (45 U.S.C 362 (o)), the Railroad Retirement Board (RRB) is entitled to reimbursement of the sickness benefits paid to a railroad employee if the employee receives a sum or damages for the same infirmity for which the benefits are paid. Section 2(f) of the RUIA requires employers to reimburse the RRB for days in which salary, wages, pay for time lost or other remuneration is later determined to be payable. Reimbursements under section 2(f) generally result from the award of pay for time lost or the payment of guaranteed wages. The RUIA prescribes that the amount of benefits paid be deducted and held by the employer in a special fund for reimbursement to the RRB.
The RRB currently utilizes Forms SI-1c, Supplemental Information on Accident and Insurance; SI-5, Report of Payments to Employee Claiming Sickness Benefits Under the RUIA; ID-3s and ID-3s (internet), Request for Lien Information—Report of Settlement; ID-3s-1, Lien Information Under Section 12(o) of the RUIA; ID-3u and ID-3u (internet), Request for Section 2(f) Information; ID-30k, Notice to Request Supplemental Information on Injury or Illness; and ID-30k-1, Notice to Request Supplemental Information on Injury or Illness; to obtain the necessary information from claimants and railroad employers. Completion is required to obtain benefits. One response is requested of each respondent.
*Previous Requests for Comments:* The RRB has already published the initial 60-day notice (85 FR 57257 on September 15, 2020) required by 44 U.S.C. 3506(c)(2). That request elicited no comments.
**Information Collection Request (ICR)**
*Title:* Supplemental Information on Accident and Insurance.
*OMB Control Number:* 3220-0036.
*Form(s) submitted:* SI-1c, SI-5, ID-3s, ID-3s (internet), ID-3s.1, ID3u, ID-3u (internet), ID-30k, and ID-30k.1.
*Type of request:* Revision of a currently approved collection of information.
*Affected public:* Individuals or Households.
*Abstract:* The Railroad Unemployment Insurance Act provides for the recovery of sickness benefits paid if an employee receives a settlement for the same injury for which benefits were paid. The collection obtains information that is needed to determine the amount of the RRB's reimbursement from the person or company responsible for such payments.
*Changes proposed:* The RRB proposes no changes to SI-1c, SI-5, ID-3s, ID-3s (internet), ID-3u, ID-3u (internet), and ID-30k. The RRB proposes to remove Form ID-30K-1 from the Information Collection due to less than 10 responses per year.
The burden estimate for the ICR is as follows:
| Form No. | Annual | Time | Burden |
| --- | --- | --- | --- |
| SI-1c | 1,700 | 5 | 142 |
| SI-5 | 100 | 5 | 8 |
| ID-3s (paper & telephone) | 2,000 | 3 | 100 |
| ID-3s (Internet) | 2,000 | 3 | 100 |
| ID-3s-1 (paper & telephone) | 1,200 | 3 | 60 |
| ID-3u (paper & telephone) | 1,000 | 3 | 50 |
| ID-3u (Internet) | 800 | 3 | 40 |
| ID-30k | 100 | 5 | 8 |
| Total | 8,900 | | 508 |
2. *Title and Purpose of information collection:* Pension Plan Reports; OMB 3220-0089. Under Section 2(b) of the Railroad Retirement Act (RRA) (45 U.S.C. 231a), the Railroad Retirement Board (RRB) pays supplemental annuities to qualified RRB employee annuitants. A supplemental annuity, which is computed according to Section 3(e) of the RRA, can be paid at age 60 if the employee has at least 30 years of creditable railroad service or at age 65 if the employee has 25-29 years of railroad service. In addition to 25 years of service, a “current connection” with the railroad industry is required. Eligibility is further limited to employees who had at least 1 month of rail service before October 1981 and were awarded regular annuities after June 1966. Further, if an employee's 65th birthday was prior to September 2, 1981, he or she must not have worked in rail service after certain closing dates (generally the last day of the month following the month in which age 65 is attained). Under Section 2(h)(2) of the RRA, the amount of the supplemental annuity is reduced if the employee receives monthly pension payments, or a lump-sum pension payment from a private pension from a railroad employer, to the extent the payments are based on contributions from that employer. The employee's own contribution to their pension account does not cause a reduction. A private railroad employer pension is defined in 20 CFR 216.42.
The RRB requires the following information from railroad employers to calculate supplemental annuities: (a) The current status of railroad employer pension plans and whether such plans cause reductions to the supplemental annuity; (b) whether the employee receives monthly payments from a private railroad employer pension, elected to receive a lump sum in lieu of monthly pension payments from such a plan, or was required to receive a lump sum from such a plan due to the plan's small benefit provision; and (c) the amount of the payments attributable to the railroad employer's contributions. The requirement that railroad employers furnish pension information to the RRB is contained in 20 CFR 209.2.
The RRB currently utilizes Form G-88p and G-88p (internet), *Employer's Supplemental Pension Report,* and Form G-88r, *Request for Information About New or Revised Employer Pension Plan,* to obtain the necessary information from railroad employers. One response is requested of each respondent. Completion is mandatory.
*Previous Requests for Comments:* The RRB has already published the initial 60-day notice (85 FR 57257 on September 15, 2020) required by 44 U.S.C. 3506(c)(2). That request elicited no comments.
**Information Collection Request (ICR)**
*Title:* Pension Plan Reports.
*OMB Control Number:* 3220-0089.
*Forms submitted:* G-88p and G-88r.
*Type of request:* Revision of a currently approved collection of information.
*Affected public:* Businesses or other for-profits.
*Abstract:* The Railroad Retirement Act provides for payment of a supplemental annuity to a qualified railroad retirement annuitant. The collection obtains information from the annuitant's employer to determine (a) the existence of railroad employer pension plans and whether such plans, if they exist, require a reduction to supplemental annuities paid to the employer's former employees and (b) the amount of supplemental annuities due railroad employees.
*Changes proposed:* The RRB proposes no changes to G-88P and G-88P (internet). The RRB proposes the following minor non-burden impacting changes to Form G-88R: change work unit contact from “RAC” to “SESC” and update the fax number to the current number.
*The burden estimate for the ICR is as follows:*
| Form No. | Annual | Time | Burden |
| --- | --- | --- | --- |
| G-88p | 100 | 8 | 13 |
| G-88p (Internet) | 200 | 6 | 20 |
| G-88r | 10 | 8 | 1 |
| Total | 310 | | 34 |
*3. Title and Purpose of information collection:* Statement Regarding Contributions and Support; OMB 3220-0099.
Under Section 2 of the Railroad Retirement Act (45 U.S.C. 231a), dependency on an employee for one-half support at the time of the employee's death can affect (1) entitlement to a survivor annuity when the survivor is a parent of the deceased employee; (2) the amount of spouse and survivor annuities; and (3) the Tier II restored amount payable to a widow(er) whose annuity was reduced for receipt of an employee annuity, and who was dependent on the railroad employee in the year prior to the employee's death. One-half support may also negate the public service pension offset in Tier I for a spouse or widow(er). The Railroad Retirement Board (RRB) utilizes Form G-134, Statement Regarding Contributions and Support, to secure information needed to adequately determine if the applicant meets the one-half support requirement. One response is completed by each respondent. Completion is required to obtain benefits.
*Previous Requests for Comments:* The RRB has already published the initial 60-day notice (85 FR 57258 on September 15, 2020) required by 44 U.S.C. 3506(c)(2). That request elicited no comments.
**Information Collection Request (ICR)**
*Title:* Statement Regarding Contributions and Support.
*OMB Control Number:* 3220-0099.
*Form(s) submitted:* G-134.
*Type of request:* Revision of a currently approved collection of information.
*Affected public:* Individuals or Households.
*Abstract:* Dependency on the employee for one-half support at the time of the employee's death can be a condition affecting eligibility for a survivor annuity provided for under Section 2 of the Railroad Retirement Act. One-half support is also a condition which may negate the public service pension offset in Tier I for a spouse or widow(er).
*Changes proposed:* The RRB proposes a minor editorial change to Form G-134 to change the date under Section 1 “General Instructions”..
The burden estimate for the ICR is as follows:
| Form No. | Annual | Time | Burden |
| --- | --- | --- | --- |
| G-134 | | | |
| With assistance | 75 | 147 | 184 |
| Without assistance | 25 | 180 | 75 |
| Total | 100 | | 259 |
*4. Title and purpose of information collection:* Financial Disclosure Statement; OMB 3220-0127.
Under Section 10 of the Railroad Retirement Act and Section 2(d) of the Railroad Unemployment Insurance Act (45 U.S.C. 231i), the RRB may recover overpayments of annuities, pensions, death benefits, unemployment benefits, and sickness benefits that were made erroneously. An overpayment may be waived if the beneficiary was not at fault in causing the overpayment and recovery would cause financial hardship. The regulations for the recovery and waiver of erroneous payments are contained in 20 CFR 255 and CFR 340.
The RRB utilizes Form DR-423, Financial Disclosure Statement, to obtain information about the overpaid beneficiary's income, debts, and expenses if that person indicates that (s)he cannot make restitution for the overpayment. The information is used to determine if the overpayment should be waived as wholly or partially uncollectible. If waiver is denied, the information is used to determine the size and frequency of installment payments. The beneficiary is made aware of the overpayment by letter and is offered a variety of methods for recovery. One response is requested of each respondent. Completion is voluntary. However, failure to provide the requested information may result in a denial of the waiver request.
*Previous Requests for Comments:* The RRB has already published the initial 60-day notice (85 FR 57258 on September 15, 2020) required by 44 U.S.C. 3506(c)(2). That request elicited no comments.
**Information Collection Request (ICR)**
*Title:* Financial Disclosure Statement.
*OMB Control Number:* 3220-0127.
*Form(s) submitted:* DR-423.
*Type of request:* Extension without change of a currently approved collection.
*Affected public:* Individuals or Households.
*Abstract:* Under the Railroad Retirement and the Railroad Unemployment Insurance Acts, the Railroad Retirement Board has authority to secure from an overpaid beneficiary a statement of the individual's assets and liabilities if waiver of the overpayment is requested.
*Changes proposed:* The RRB proposes no changes to Form DR-423.
*The burden estimate for the ICR is as follows:*
| Form No. | Annual | Time | Burden |
| --- | --- | --- | --- |
| DR-423 | 1,200 | 85 | 1,700 |
5. *Title and purpose of information collection:* Representative Payee Monitoring; OMB 3220-0151.
Under Section 12 of the Railroad Retirement Act (RRA) (45 U.S.C. 231k), the RRB may pay annuity benefits to a representative payee when an employee, spouse, or survivor annuitant is incompetent or a minor. The RRB is responsible for determining if direct payment to an annuitant or a representative payee would best serve the annuitant's best interest. The accountability requirements authorizing the RRB to conduct periodic monitoring of representative payees, including a written accounting of benefit payments received, are prescribed in 20 CFR 266.7. The RRB utilizes the following forms to conduct its representative payee monitoring program.
Form G-99a, *Representative Payee Report,* is used to obtain information needed to determine whether the benefit payments certified to the representative payee have been used for the annuitant's current maintenance and personal needs and whether the representative payee continues to be concerned with the annuitant's welfare. RRB Form G-99c, *Representative Payee Evaluation Report,* is used to obtain more detailed information from a representative payee who fails to complete and return Form G-99a or in situations when the returned Form G-99a indicates the possible misuse of funds by the representative payee. Form G-99c contains specific questions concerning the representative payee's performance and is used by the RRB to determine whether or not the representative payee should continue in that capacity.
Form G-106, *Statement of Care and Responsibility to Annuitant,* is used to solicit information about the representative payee's performance and the annuitant's well-being from the custodian of the annuitant. The form contains specific questions concerning the representative payee's performance, and is used by the RRB to determine whether or not the representative payee should continue in that capacity. Completion of the forms in this collection is required to retain benefits.
*Previous Requests for Comments:* The RRB has already published the initial 60-day notice (85 FR 57258 on September 15, 2020) required by 44 U.S.C. 3506(c)(2). That request elicited no comments.
**Information Collection Request (ICR)**
*Title:* Representative Payee Monitoring.
*OMB Control Number:* 3220-0151.
*Forms submitted:* G-99a, G-99c and G-106.
*Type of request:* Revision of a currently approved collection.
*Affected public:* Individuals or Households.
*Abstract:* Under Section 12(a) of the Railroad Retirement Act, the RRB is authorized to select, make payments to, and conduct transactions with an annuitant's relative or some other person willing to act on behalf of the annuitant as representative payee. If the representative payee does not have custody of the beneficiary, the RRB will obtain the information from the custodian for evaluation. The collection obtains information needed to determine if a representative payee is handling benefit payments in the best interest of the annuitant.
*Changes proposed:* The RRB proposes the following changes to Form G-99a: add drop-down box “Second Request” at the top of the form to when the RRB needs to follow-up with a Representative Payee who did not respond to the initial request, add computer-generated address fields to mail the form to a Representative Payee, and slight change to question's 1, 3, and 9 wording to clarify and improve the reliability of responses. The RRB proposes the following change to Form G-99c: slight change question 9 wording to clarify and improve the reliability of responses. The RRB proposes no changes for Form G-106.
*The burden estimate for the ICR is as follows:*
| Form No. | Annual | Time | Burden |
| --- | --- | --- | --- |
| G-99a (legal and all other, excepting parent for child) | 5,400 | 18 | 1,620 |
| G-99c (Parts I and II) | 300 | 24 | 120 |
| G-99c (Parts I, II, and III) | 120 | 31 | 62 |
| G-106 | 500 | 10 | 83 |
| Total | 6,320 | | 1,885 |
*6. Title and purpose of information collection:* Representative Payee Parental Custody Monitoring; OMB 3220-0176.
Under Section 12(a) of the Railroad Retirement Act (RRA) (45 U.S.C. 231k), the Railroad Retirement Board (RRB) is authorized to select, make payments to, and to conduct transactions with, a beneficiary's relative or some other person willing to act on behalf of the beneficiary as a representative payee. The RRB is responsible for determining if direct payment to the beneficiary or payment to a representative payee would best serve the beneficiary's interest. Inherent in the RRB's authorization to select a representative payee is the responsibility to monitor the payee to assure that the beneficiary's interests are protected. The RRB utilizes Form G-99D, Parental Custody Report, to obtain information needed to verify that a parent-for-child representative payee still has custody of the child. One response is required from each respondent.
*Previous Requests for Comments:* The RRB has already published the initial 60-day notice (85 FR 58077 on September 17, 2020) required by 44 U.S.C. 3506(c)(2). That request elicited no comments.
**Information Collection Request (ICR)**
*Title:* Representative Payee Parental Custody Monitoring.
*OMB Control Number:* 3220-0176.
*Form(s) submitted:* G-99D.
*Type of request:* Revision of a currently approved collection.
*Affected public:* Individuals or households.
*Abstract:* Under Section 12(a) of the Railroad Retirement Act, the RRB is authorized to select, make payments to, and conduct transactions with an annuitant's relative or some other person willing to act on behalf of the annuitant as a representative payee. The collection obtains information needed to verify the parent-for-child payee still retains custody of the child.
*Changes proposed:* The RRB proposes the following changes to Form G-99d:
• Minor change item 4 layout.
• Add new item 6 to solicit the total amount of railroad retirement benefits received for the child during the reporting period.
• Add new item 7 to solicit the dollar amount of railroad retirement benefits used for the child during the reporting period.
• Add new item 8 to solicit a description of how the railroad retirement benefits were used for the child during the reporting period.
• Add new item 9 to solicit how the surplus railroad retirement benefits, if any, were held for the child, for example, in cash, a checking account, a savings account, or other means and the tittle of any checking or savings accounts holding surplus benefits.
• Renumbered item 6 Certification to item 10.
• Update to the Paperwork Reduction Act and Privacy Act Notices to change the burden time from 5 to 15 minutes.
*The burden estimate for the ICR is as follows:*
| Form No. | Annual | Time | Burden |
| --- | --- | --- | --- |
| G-99D | 2,100 | 15 | 525 |
*7. Title and Purpose of information collection: Earnings Information Request; OMB 3220-0184* .
Under Section 2 of the Railroad Retirement Act (45 U.S.C. 231a), an annuity is not payable, or is reduced for any month(s) in which the beneficiary works for a railroad or earns more than prescribed amounts. The provisions relating to the reduction or non-payment of annuities by reason of work are prescribed in 20 CFR 230.
The RRB utilizes Form G-19-F, *Earnings Information Request,* to obtain earnings information that either had not been previously reported or erroneously reported by a beneficiary.
Currently the claimant is asked to enter the date they stopped working, if applicable. If a respondent fails to complete the form, the RRB may be unable to pay them benefits. One response is requested of each respondent.
*Previous Requests for Comments:* The RRB has already published the initial 60-day notice (85 FR 57259 on September 15, 2020) required by 44 U.S.C. 3506(c)(2). That request elicited no comments.
**Information Collection Request (ICR)**
*Title:* Earnings Information Request.
*OMB Control Number:* 3220-0184.
*Form(s) submitted:* G-19-F.
*Type of request:* Extension without change of a currently approved collection.
*Affected public:* Individuals or Households.
*Abstract:* Under Section 2 of the Railroad Retirement Act, an annuity is not payable, or is reduced for any month(s) in which the beneficiary works for a railroad or earns more than prescribed amounts. The collection obtains earnings information not previously or erroneously reported by a beneficiary.
*Changes proposed:* The RRB proposes no changes to the Form G-19-F.
The burden estimate for the ICR is as follows:
| Form No. | Annual | Time | Burden |
| --- | --- | --- | --- |
| G-19-F | 900 | 8 | 120 |
*8. Title and Purpose of information collection:* Job Information Report, OMB 3220-0193. The Railroad Retirement Board (RRB) occupational disability standards allow the RRB to request job information from railroad employers to determine an applicant's eligibility for an occupational disability.
To determine an occupational disability, the RRB must obtain the employee's work history and establish if the employee is precluded from performing his or her regular railroad occupation. This is accomplished by comparing the restrictions caused by the impairment(s) against the employee's ability to perform his or her job duties.
To collect the information needed to determine the effect of a disability on an employee applicant's ability to work, the RRB utilizes Form G-251, *Vocational Report* (OMB 3220-0141) which is completed by the applicant.
Form G-251A, Railroad Job Information, requests railroad employers to provide information regarding whether the employee has been medically disqualified from their railroad occupation; a summary of the employee's duties; the machinery, tools and equipment used by the employee; the environmental conditions under which the employee performs their duties; all sensory requirements (vision, hearing, speech) needed to perform the employee's duties; the physical actions and amount of time (frequency) allotted for those actions that may be required by the employee to perform their duties during a typical work day; any permanent working accommodations an employer may have made due to the employee's disability; as well as any other relevant information they may choose to include. Completion is voluntary.
*Previous Requests for Comments:* The RRB has already published the initial 60-day notice (85 FR 57259 on September 15, 2020) required by 44 U.S.C. 3506(c)(2). That request elicited no comments.
*Title:* Job Information Report.
*OMB Control Number:* 3220-0193.
*Form(s) submitted:* G-251A.
*Type of request:* Extension without change of a currently approved collection.
*Affected public:* Businesses or other for profits.
*Abstract:* The collection obtains information used by the Railroad Retirement Board (RRB) to assist in determining whether a railroad employee is disabled from his or her regular occupation. It provides railroad employers with the opportunity to provide information to the RRB regarding the employee applicant's job duties.
*Changes proposed:* The RRB proposes no changes to Form G-251A.
The burden estimate for the ICR is as follows:
| Form No. | Annual | Time | Burden |
| --- | --- | --- | --- |
| G-251A | 500 | 60 | 500 |
*9. Title and purpose of information collection:* Statement Regarding Contributions and Support of Children; OMB 3220-0195.
Section 2(d)(4) of the Railroad Retirement Act (RRA) (45 U.S.C. 231a), provides, in part, that a child is deemed dependent if the conditions set forth in Section 202(d)(3), (4) and (9) of the Social Security Act are met. Section 202(d)(4) of the Social Security Act, as amended by Public Law 104-121, requires as a condition of dependency, that a child receives one-half of his or her support from the stepparent. This dependency impacts upon the entitlement of a spouse or survivor of an employee whose entitlement is based upon having a stepchild of the employee in care, or on an individual seeking a child's annuity as a stepchild of an employee. Therefore, depending on the employee for at least one-half support is a condition affecting eligibility for increasing an employee or spouse annuity under the social security overall minimum provisions on the basis of the presence of a dependent child, the employee's natural child in limited situations, adopted children, stepchildren, grandchildren, step-grandchildren and equitably adopted children. The regulations outlining child support and dependency requirements are prescribed in 20 CFR 222.50-57.
In order to correctly determine if an applicant is entitled to a child's annuity based on actual dependency, the RRB uses Form G-139, Statement Regarding Contributions and Support of Children, to obtain financial information needed to make a comparison between the amount of support received from the railroad employee and the amount received from other sources. Completion is required to obtain a benefit. One response is required of each respondent.
*Previous Requests for Comments:* The RRB has already published the initial 60-day notice (85 FR 57260 on September 15, 2020) required by 44 U.S.C. 3506(c)(2). That request elicited no comments.
**Information Collection Request (ICR)**
*Title:* Statement Regarding Contributions and Support of Children.
*OMB Control Number:* 3220-0195.
*Form(s) submitted:* G-139.
*Type of request:* Revision of a currently approved collection of information.
*Affected public:* Individuals or Households.
*Abstract:* Dependency on the employee for at least one-half support is a condition affecting eligibility for increasing an employee or spouse annuity under the social security overall minimum provisions on the basis of the presence of a dependent child, the employee's natural child in limited situations, adopted children, stepchildren, grandchildren and step-grandchildren. The information collected solicits financial information needed to determine entitlement to a child's annuity based on actual dependency.
*Changes proposed:* The RRB proposes a minor editorial change to Form G-139 to change the date under Section 1 “General Instructions”.
The burden estimate for the ICR is as follows:
| Form No. | Annual | Time | Burden |
| --- | --- | --- | --- |
| G-139 | 500 | 60 | 500 |
*Additional Information or Comments:* Copies of the forms and supporting documents can be obtained from Kennisha Tucker at (312) 469-2591 or *[email protected].* Comments regarding the information collection should be addressed to Brian Foster, Railroad Retirement Board, 844 North Rush Street, Chicago, Illinois, 60611-1275 or *[email protected].*
Written comments and recommendations for the proposed information collection should be sent within 30 days of publication of this notice to *www.reginfo.gov/public/do/PRAMain.* Find this particular information collection by selecting “Currently under 30-day Review—Open for Public Comments” or by using the search function.
Brian Foster,
Clearance Officer.