DR-423 (proposed) Financial Disclosure Statement

,

UNITED STATES OF AMERICA
RAILROAD ETIREMENT BOARD

FORM APPROVED

O.M.B. NO. 3220-0127

Note: Before completing this form, you are advised to read the
PAPERWORK REDUCTION ACT/PRIVACY ACT NOTICES on page 7 of this form.
Type or print legibly in ink. 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 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 of this form, including suggestions for reducing
completion time to:
Chief of Information Resources
Management Center, Railroad Retirement Board, 844 North
Rush Street, Chicago, IL 60611-2092.
Return the completed form in the envelope provided to
you by the Railroad Retirement Board office handling
your case.

For RRB Use Only
's Retirement Claim Number:
Billina Document Number: B

Check the information entered by the Railroad Retirement Board (RRB) in items 1 through 3 to be sure it is correct.
9 If the information has not been entered in items 1 through 3, please enter the information.
9 If the information has been entered by the RRB but that information is incorrect, please cross out the incorrect
information and enter the correct information above it.
9 If the information is correct, go to item 4.

1
2

-b

RAILROADEMPLOYEE'SNAME

~p

-

-

YOURNAME

3 YOURSTREET ADDRESS
4

YOURCITY, STATE AND ZIP CODE

5

YOURDAYTIME TELEPHONE NUMBER (INCLUDEAREA CODE)

+

-

-

-

-

-b

+
+

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. ao to item 8.

6

YOURSPOUSE'S NAME

7

YOURSPOUSE'SAGE

+
+

Form DR-423 (xx-xx) Page 1 (DESTROY
PRIOREDITIONS)

Complete item 4? only if you, y

r

or d.tqwnrt8~1e cm&y ~SJISyed.If -%Q

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.

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.
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 need additional space fur entries or explanations,
use the remarks area'in Section 9. If an answer is zero,
enter "0."
Form DR-423 (+WQ Page 2
xg- K,f

ta Section 3.

,

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 inonthly.average
based on the past twelve months.
If you need additional space for enhies or explanations,
use the remarks area in Section 9. If an answer is zero,
enter "0."

MONTHLY
INCOME

a

YOU

I SPOUSE
YOUR 11 fl,

AVERAGE EARNINGS FROM
EMPLOYMENT OR SELF-EMPLOYMENT

b RAILROAD RETIREMENT
C

I

I

I

It

vate pension, insurance, blacklung,
unemployment, SSI)

I

SELF
DEPENDENTS
AND ALL

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

1I

SOCIAL SECURITY

d OTHER BENEFITS (civil service, VA, pri-

MONTHLY
HOUSEHOLDEXPENSES

1 1 /I

C ELECTRICITY (average for the past 12
months)

d HEAT (average for the past
12months)

e WELFARE (local welfare or
public assistance)

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

f TRANSPORTATION(gasoline, oil,
.

carfare, taxi, etc.)

g INSURANCE (include health, life,

Q CONTRIBUTIONS FROM RELATIVES

auto, home, renter's)

h TOTAL MONTHLY INCOME
(add lines lp?a - I&&)
i

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

h CLOTHING

on line pfh)
*

j

INCOM~~OF
DEPENDENTS OTHER THAN
YOUR SPOUSE (income for those listed

k

TOTAL MONTHLY FAMILY INCOME (totat

-

"
of l i n e s 9 and#)

'd

9'

.

i

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

j

OTHER LIVING EXPENSES (specify in

remarks)

k TOTAL MONTHLY HOU
(total of lines@I

- $f

HOLD EXPENSES

List the details of all outstanding bdances for which you pr&ntly 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."

Form DR-423 (11-06) Page 3

-

DETAILSOF OTHERDEBTS

IL( 3

DATEDEBT

NAMEOF
CREDITOR

PURPOSE
OF

INCURRED
DEBT

a

b
C
I
I+

I

d

I
TOTALUNPAID BALANCE (add lines &a

- ldc)

e TOTALMONTHLY PAYMENTS (add lines

f TOTALMONTHLY HOUSEHOLD EXPENSES(from item
g TOTALMONTHLY EXPENSES (add lines

1t9

and

16
d TOTALMONTHLY FAMILYl i r ~ h(fmm
k item w, Section 3)

'# TOTAL

MONTHLY EXPENSES (from item

9

Section 5)

I

6
36

BALANCE(subtract line

w~h$~~

HOW MUCH OF THE BALANCE ON LINE
APPLY MONTHLY TO
YOUR M B T T o THE RAILROAD RETIREMENT BOARD?

Form DR-423 (13-86)Page 4

7%-)q€

ORIGINAL
AMOUNT

UNPAID
BALANCE

MONTHLY
PAYMENT

~0 #a

II

CASHIN BANK OR OTHER
FINANCIAL INSTITUTIONS

g CASHVALUE OF LIFE lNSURUlCE

(checking.and savings)

b CASHONHAND

i VALUEOFHOME

C AUTOMOBILES
(resale value)

j VALUEOF OTHER REAL'ESTATE

d RH=W~IONALVEHICLES (resale value)

e

I

OTHERASSETS (attach list or explain
in Section 9)

I TOTALASSETS

CERTIFICATES OF DEPOSIT

f U.S. SAVINGS
BONDS

(add lines#a

I

-;dL)

I n ~W

I

HAVEYOU BEEN DECLARED BANKRUPT DUMNG
THE PAST SEVEN YEARS?

a
3-3-

YES (if yes, complete date dischargedand
court location)

HAVEYOU FILED A FEDERAL INCOMETAX RETURN WITHIN THE LAST TWO YEARS?

0

YES (if yes. you niust furnish a k p y of your latest return)

0

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 PROPERTYW U L D INCLUDE CASH, SAVINGS, JEWELRY. BONDS, STOCKS. REAL ESTATE, ETC.

0

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

Form DR-423 (W)
Page 5

29-q

IF YOU NEED MORE SPACE, APACHADDITIONAL 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.

I
If you and/or your spouse signed this statement by mark (%"), two witnesses who know you must sign
below giving their full address.
S~GNATURE
OF WITNESS

Address (number and street)

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

32 (
SIGNATURE
OF WITNESS

)

Address (number and street)

City,state and ZIP code
.

Telephone number (include area code)

Form DR-423(-44-86) Page 6

.

The ÿ ail road Retirement Board (RRB) is
authorized to collect the above information
u n d e r section 7b(6) of t h e ~ a i l r b a d
Retirement Act and under section 12(1) of
the Railroad Unemployment Insurance Act.
If a n overpayment of benefits h a s been
made to you, this information will enable
t h e RRB t o 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 w i t h t h e overpayment a n d
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, i g 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 import a n t 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
r e p o r t t h e overpayment t o a n o t h e r
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 t h e prior
written consent of the person t o whom
t h e information or record applies. The
routine uses or disclosures.which may be
m a d e of inform-ation from t h i s form
include the following:
3

Information or records may be
disclosed to any last employer to
verify statement(s) of earnings.
Information or records may be
disclosed t o the -C704ccn
4k?#&%&!&
Office for auditing of
debts arising from overpayments
under either t h e Railroad
Retirement o r Social Security
Acts.

m
.

.

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
a p p r o p r i a t e Federal, s t a t e o r
local enforcement agency.

The RRB's current list of routine uses may be inspected at any.ofie of the RRB.
Form DR-423

.>

(wPage 7
=-x%

~

+