Form DR-423 (05-09) DR-423 (05-09) Financial Disclosure Statement

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

FORM APPROVED

OMB No. 3220-0127

FINANCIAL DISCLOSURE STATEMENT

GENERAL INSTRUCTIONS
Note: Before completing this form, you are advised to read the

PAPERWORK REDUCTION/PRIVACY ACT NOTICE 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 i,n 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" instruc­
tions 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: 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.

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

5

YOUR DAYTIME TELEPHONE NUMBER (include area code)

ZIP CODE
~

!r

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 (05-O9) 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)

AGE

NAME OF DEPENDENT

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
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.

SECTION

4· MONTHLY HOUSEHOLD EXPENSES

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."

Fonn DR-423 (05-09) 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

d

OTHER BENEFITS (civil service, VA, pri­
vate 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.)

9

CONTRIBUTIONS FROM RELATIVES

9

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
in item 8)

i

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

k

TOTAL MONTHLY FAMILY INCOME (total
of lines 10i and 1OJ)

j

OTHER LIVING EXPENSES (specify in
remarks)

k

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

SELF AND ALL
DEPENDENTS

months)

SECTION

"

5 - SUMMARY OF DEBTS

List the details of all outstanding balances for which you presently make monthly payments. Items
14a, band 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 (05-09) Page 3

DETAILS OF OTHER DEBTS

14

NAME OF CREDITOR

DATE DEBT

PURPOSE OF

ORIGINAL

UNPAID

MONTHLY

INCURRED

DEBT

AMOUNT

BALANCE

PAYMENT

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)

9

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 OFTHE 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 (05-09) Page 4

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
FINANCIAL INSTITUTIONS

9

CASH VALUE OF LIFE INSURANCE

(checking and savings)

h

STOCKS AND OTHER BONDS

i

VALUE OF HOME

C AUTOMOBILES (resale value)

j

VALUE OF OTHER REAL ESTATE

d

RECREATIONAL VEHICLES (resale value)

k

OTHER ASSETS (attach list or explain

e

CERTIFICATES OF DEPOSIT

I

TOTAL ASSETS (add lines 20a ­

f

U.S. SAVINGS BONDS

b

CASH ON HAND

SECTION
21

22

23

20k)

8 - ADDITIONAL FINANCIAL INFORMATION

HAVE YOU BEEN DECLARED BANKRUPT DURING
THE PAST SEVEN YEARS?

o
o

in Section 9)

DATE
DISCHARGED

COURT LOCATION

YES (if yes, complete date discharged and
court location)
NO

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

o
o

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.

o
o

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

NO

Form DR-423 (05-09) Page 5

SECTION

9 - REMARKS

Item No. 24

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 lor 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

1)'(

)

1)'(

)

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

Form

DR·423 (05-09) Page 6

PAPERWORK REDUCTION/PRIVACY ACT NOTICE

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(1) 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 overpay­
ment. 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 impor­
tant in establishing the rate of recovery
or the extent of the recovery efforts.

You are not required to provide the infor­
mation 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 informa­
tion 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 audit­
ing of debts arising from over­
payments 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 (05-09) Page 7