Form DR-423 Financial Disclosure Statement

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

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

Note: Before completing this form, you are advised to read the
PAPERWORK REDUCTION/PRIVACYACT NOTICE on page 7 of this form.
Print all answers in ink or use a typewriter. If you need
more space than is provided to answer the 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
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
the completion time to: Chief of lnformation Resources
Management Center, Railroad Retirement Board, 844 North
Rush Street, Chicago, IL 60611-2092.
Please, do not return t h e form to the Chief of
lnformation Resources Management Center. Return
the completed form in the envelope provided to you by
the Railroad Retirement Board office handling your case.

Look over any information entered by the RRB for items 1 through 7 to be sure it is correct. If the information has
not been entered for these items, please enter the information. If the information entered by the RRB is not
correct, enter the correct information in Section 9 and then go to item 8.

2 RAILROAD
EMPLOYEE'S RETIREMENT CLAIM NUMBER

3 YOURSOCIAL SECURITY NUMBER
4 YOURNAME

7 YOURDAYTIME TELEPHONE NUMBER (include area code)

-

--

XXX-XXXXx-XX-

Complete items 8 a n d T i n l y if you are currently married, or were previously married and your former
spouse receives benefits from the Railroad Retirement Board. Otherwise, go to item 10.

9

j

YOUR SPOUSE~SAGE +
I

9a YOURSPOUSE~SSOCIAL SECURITY NUMBER

-

I

I

I
I

I
I

I

I

Form DR-423 (1 1-06) Page I(DESTROY
PRIOREDITIONS)

Complete item 10 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 11.

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

Complete item 11 only if you, your spouse or dependents are currently employed. Otherwise, go to Section 3.

11

EMPLOYER'S
NAMEAND ADDRESS

NAMEOF EMPLOYED
INDIVIDUAL

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."
I

Form DR-423 (1 1-06) Page 2

I

12
a
b

MONTHLY
INCOME

YOUR
SPOUSE

I3

AVERAGE EARNINGS FROM
EMPLOYMENT OR SELF-EMPLOYMENT

a

RAILROAD RETIREMENT

b

C SOCIAL SECURITY

d

YOU

MONTHLYHOUSEHOLD
EXPENSES
RENT OR MORTGAGE (include any

property taxes in this amount)
FOOD

C ELECTRICITY (average for the past 12
months)

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

d

WELFARE (local welfare or

e

TELEPHONE

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

f

TRANSPORTATION (gasoline, oil,

g

CONTRIBUTIONS FROM RELATIVES

g

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

h

TOTAL MONTHLY INCOME

i

COMBINED MONTHLY INCOME OF YOU
AND YOUR SPOUSE (add both amounts

h

CLOTHING

i

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

j

OTHER LIVING EXPENSES (specify in

e

public assistance)

f

SELF AND ALL
DEPENDENTS

HEAT (average for the past

12 months)

carfare, taxi, etc.)

(add lines 12a - 129)

on line 12h)

j

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

in item 10)

k

TOTAL MONTHLY FAMILY INCOME (total

remarks)

of lines 12i and 12j)

k

TOTAL MONTHLY HOUSEHOLD EXPENSES

(total of lines 13a - 13j)

List the details of all outstanding balances for which you presently make monthly payments. Items
16a, 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."

Form DR-423(1 1-06) Page 3

DETAILS OF OTHER DEBTS

16 NAMEOF CREDITOR

DATEDEBT
INCURRED

PURPOSE
OF
DEBT

ORIGINAL
AMOUNT

UNPAID
BALANCE

a
b
C

d TOTALUNPAID BALANCE (add lines 16a - 1 6 ~ )
t?

TOTALMONTHLY PAYMENTS (add lines 16a - 1 6 ~ )

f TOTALMONTHLY HOUSEHOLD EXPENSES (from item 13k, Section 4)

g TOTALMONTHLY EXPENSES (add lines 16e and 16f)

Enter the amount as shown in the items previously completed. If an answer is zero, enter "0."

17 TOTALMONTHLY FAMILY INCOME (from item 12k, Section 3)
18 TOTALMONTHLY EXPENSES (from item 16g, Section 5)
19 BALANCE
(subtract line 18 from line 17)
20

HOWMUCH OF THE BALANCE ON LINE 19 CAN YOU APPLY MONTHLY TO
YOUR DEBT T o THE RAILROAD RETIREMENT BOARD?

21

IFYOUR TOTAL MONTHLY EXPENSES EXCEED INCOME. HOW DO YOU PAY THE
DIFFERENCE?
USESECTION
9 TO CONTINUE YOUR EXPLANATION IF NECESSARY.

Form DR-423 (1 1-06) Page 4

MONTHLY
PAYMENT

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."

22a CASHIN BANK OR OTHER

g CASHVALUE OF LIFE INSURANCE

FINANCIAL INSTITUTIONS

(checking and savings)

h STOCKSAND OTHER BONDS

b CASHON HAND

i VALUEOF HOME

C AUTOMOBILES
(resale value)

j VALUEOF OTHER REAL ESTATE
OTHERASSETS (attach list or explain

d RECREATIONAL
VEHICLES (resale value)
e CERTIFICATES
OF DEPOSIT

in Section 9)

I

TOTALASSETS (add lines 22a - 22k)

f U.S. SAVINGSBONDS

23

HAVEYOU BEEN DECLARED BANKRUPT DURING
THE PAST SEVEN YEARS?

DATE
DISCHARGED

COURTLOCATION

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

Ll
24

HAVEYOU 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)

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

Form DR-423 (1 1-06) Page 5

Item No. 26

IF YOU NEED MORE SPACE, ATTACH ADDITIONAL SHEETS

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.

YOURSPOUSE'S SIGNATURE
I

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)

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

SIGNATURE
OF WITNESS

=(

)

=(

1

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

Form DR-423 (1 1-06) Page 6

The Railroad Retirement Board (RRB) is
authorized to collect the above information
under section 7b(6) of t h e Railroad
Retirement Act and under section 12(1) of
the Railroad Unemployment Insurance Act.
If a n overpayment of benefits has been
made to you, t h s information will enable
t h e 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 a t fault in
connection with t h e 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
o v e r p a y m e n t . Moreover, if t h e RRB
determines t h a t recovery may not be
waived, t h e f i n a n c i a l i n f o r m a t i o n
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 t o
report t h e 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
m a d e of i n f o r m a t i o n from t h i s 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 t o t h e G e n e r a l
Accounting Office for auditing of
debts arising from overpayments
under either t h e Railroad
Retirement or Social Security
Acts.
Information or records may be
disclosed i n 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 (11-06) Page 7