Transmittal Letter for Form G-106

UNITED STATES OF AMERICA

RAILROAD RETIREMENT BOARD

CURRENT

WWW.RRB.GOV
OFFICE HOURS: M-T-TH-F 9:00 AM TO 3:30 PM
WEDS. 9:00 AM TO 12:00 PM - CLOSED FEDERAL HOLIDAYS

TOLL-FREE NUMBER: 1-877-772-5772

,
In reply refer to
Annuitant Name:
Rep Payee Name:
RRB Claim Number:
We are monitoring the care and responsibility of the annuitant named above and our records
indicate that the annuitant resides with you. Since the representative payee does not have custody
of the annuitant, we need your assistance in providing specific information on the annuitant’s wellbeing. Please complete the enclosed Form G-106, Statement of Care and Responsibility for
Annuitant, and return to us within 15 days from the date of this letter. If you have any questions
about this form, write to us at the address shown above or telephone us at our toll-free number.
For general information about railroad retirement benefits, visit our website at www.rrb.gov.
Paperwork Reduction Act and Privacy Act Notices - The information requested on Form G-106
is needed to determine if the applicant is eligible to continue receiving benefits from the RRB. The
RRB’s authority for requesting this information is section 7(b)(6) (45 U.S.C. 231f(b)(6)) of the
Railroad Retirement Act. Although you are not required to provide this information, if you fail to do
so, we may not be able to ensure that benefits are correctly being used for the annuitant.
We estimate Form G-106 takes an average of 10 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 N. Rush Street, Chicago, Illinois 60611-1275.
Return Instructions
Please use the enclosed envelope to return the form to our office located at .

Enclosures
Form G-106
Envelope

RL-106 (xx-xx)