G-19L (proposed) Annual Earnings Questionnaire for Annuitants in Last Per

Form Approved
OMB NO.3220-0179

In reply refer to
Date of Birth:
Work Deduction Amount: $

Our records show that part of your annuity is being reduced because you are working for your last
pre-retirement, nonrailroad employer. In order for us to determine if we withheld the correct
amount, please complete the enclosed questionnaire and return it to us. Be sure to provide a
monthly breakdown of your earnings. If your annuity has been recently adjusted to remove work
deductions, please disregard this notice.
The questionnaire is divided into three parts. By following the instructions on the last page, you
should complete the parts of the questionnaire corresponding to the type of employment you had in
. Attach a copy of your Forms W-2 and a copy of your Schedule SE if vou were selfemplo~edin . Below are some guidelines and instructions that will help you complete the
questionnaire.

P You are not required to give us a monthly breakdown of your earnings and/or hours of work
if your earnings and/or hours of work were about the same in each month, including months
you were on vacation, were sick or injured, or were on continuation of pay. Write "Same"
instead.
P The total earnings you report in ltems 1,4, and 7 should match the totals on your Forms
W-2 (generally the higher amount from Box 1, 3, or 5), or the amount shown on your
Schedule SE in the item labeled "Net Earnings from Self Employment." Enter your total
earnings for
even if you do not provide a monthly breakdown of your earnings.
P Remember to provide an estimate of your earnings for all months in calendar year 1 in
ltems 2, 5, and 8.
Be sure to sign and date the form in the spaces provided. Attach your Forms W-2 or Schedule SE.
To avoid penalties, you must return the questionnaire within 30 days of the date of this letter. If
you need more time, let us know as soon as possible. We can allow additional time if you have
special circumstances.

Form G-19L (xx-xx)

If you have questions about how to corrlplete the questionnaire or about how earnings affect your
annuity, contact us at the address shown at the bottom of the enclosed questionnaire. If you write
to us, please include a copy of the questionnaire with your letter. If you visit us in person, bring the
questiorlnaire and any other information you have about your claim. We suggest you call for an
appointment. Most Railroad Retirement Board offices are open to the public from 9:00a.m. to 3:30
p.m., Monday through Friday.
Before completing the enclosed form, please read "Important Notices" below.
Sincerely,

Enclosures
Annual Earnings Questionnaire
Return Envelope

IMPORTANT NOTICES
Paperwork Reduction [Act1 and Privacv Act Notice

The U.S. Railroad Retirement Board is authorized to collect the requested information under Section 7b(6) of
the Railroad Retirement Act. This information is needed to determine whether your earnings will affect your
retirement benefits. You are not required to provide us with the information. However, if you fail to provide
the required information, we might be unable to pay you any benefits. The information you provide may be
disclosed for purposes of verification to the employers you name in the report.
We estimate the form takes an average of 15 minutes per response to complete, includirlg 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, Railroad Retirement Board, 844 N. Rush Street, Chicago, IL 606112092.
Computer Matching and Privacv Protection Act Notice

The Computer Matching and Privacy Act of 1988 requires the U.S. Railroad Retirement Board (RRB) to
advise you that information you have provided may be used, without your consent, in automated matching
programs. These matching programs are a computer comparison of RRB records with those kept by other
Federal, state, or local government agencies. lnformation from these matching programs can be used to
establish or verify a person's eligibility for federally funded or administered benefit programs and for
repayment of payments or delinquent debts under these programs.

Form G-19L (xx-xx)

Form Approved
OMB NO.3220-0179

United States of America
Railroad Retirement Board

PART C

PART B

PART A
COMPLETE THISPARTFOR
EARNINGS
THAT ARE FROM YOUR LAST
PRE-RETIREMENT (NONRAILROAD)
EMPLOYER
LAST PRE-RETIREMENT
EMPLOYER

NET SELF-EMPLOYMENT
TYPE OF WORK

OTHER POST RETIREMENT
EMPLOYER

ADDRESS

ADDRESS

ADDRESS

COMPLETE THIS PART FOR NET
SELF-EMPLOYMENT EARNINGS

EMPLOYEE IDENTIFICATION NO. (EIN)
MONTH

EARNINGS IN MONTH

COMPLETE THlS PART FOR OTHER
EARNINGS THAT ARE NOT REPORTED
IN PART A OR PART B

EMPLOYEE IDENTIFICAl-IONNO. (EIN)
EARNINGS IN MONTH

MONTH

MONTH

JANUARY

JANUARY

JANUARY

FEBRUARY

FEBRUARY

FEBRUARY

MARCH

MARCH

MARCH

APRIL

APRIL

APRIL

EARNINGS IN MONTH

MAY

MAY

MAY

JUNE

JUNE

JUNE

JULY

JULY

JULY

AUGUST

AUGUST

AUGUST

SEPTEMBER

SEPTEMBER

SEPTEMBER

OCTOBER

OCTOBER

OCTOBER

NOVEMBER

NOVEMBER

NOVEMBER

DECEMBER

DECEMBER

DECEMBER

1. TOTAL :
$0.00
2. 1 EARNINGS ESTIMATE FOR
THIS EMPLOYMENT: $
3. IF NO LONGER EMPLOYED, SHOW THE
DATE YOUR WORK ENDED:
YEAR
MO.
DAY
DATE

4. TOTAL :
$0.00
1. 1 EARNINGS ESTIMATE FOR
NET SELF-EMPLOYMENT: $
2. IF NO LONGER EMPLOYED, SHOW THE
DATE YOUR WORK ENDED:
DAY
MO.
YEAR
DATE

7. TOTAL :
$0.00
8. 1 EARNINGS ESTIMATE FOR
THIS EMPLOYMENT: $
9. IF NO LONGER EMPLOYED, SHOW THE
DATE YOUR WORK ENDED:
MO.
DAY
YEAR
DATE

Do your best to complete all items that pertain to our earnings, especially Items 1 through 9. Be sure to enclose copies of your

Forms W-2 for

and a copy of Schedule SE iiyou were self-employed.

I CERTIFY THAT THE INFORMATION I AM GIVING IS TRUE, COMPLETE, AND CORRECT. I UNDERSTAND THAT CRIMINAL AND
CIVIL PENALTIES MAY BE IMPOSED ON ME FOR FALSE AND FRAUDULENT STATEMENTS.
D A TE

SIGNATURE
Area Code

Daytime Telephone Number

(In case we have questions about your responses.)

W

MAIL YOUR COMPLETED QUES'TIONNAIRE TO:
U.S. RAILROAD RETIREMENT BOARD

Tele~honeNumber

-

-4-

Instructions for Completing the Annual Earnings Questionnaire

PART A

-

Use Part A to report earnings from your last pre-retirement non-railroad employer. This
is generally the employment you performed immediately before your annuity beginning
date.

PART 6 - Use Part B to report earnings from self-employment. If you claim self-employment but
are incorporated, report your earnings in Part C, instead of Part B. If you were age 70
or older as of January I, , do not complete Part B.
PART C - Use Part C to report work and earnings that are not reported in Parts A or 6. If you
were age 70 or older as of January I, , do not complete Part C.

Follow these instructions for completinn Parts A, B, and C:

1. Enter the name and address of your employer. If you were self-employed, show the type of
work you performed and your business address.
2. Show your earnings (and the hours you worked in self-employment) for each month in .
Complete this item only if your earnings andlor self-employment hours were not
about the same in each month. In most cases, a monthly breakdown is not required and
this step can be skipped.
3. Enter the amount of your total earnings for
(Items 1,4, and 7). The amount you enter
should be the same as the amount(s) shown on your Forms W-2, or Schedule SE if you
were self-employed.

4. Enter an estimate of your earnings for 1 (Items 2, 5, and 8).

5. If you stopped working, show the date you stopped work (Items 3, 6, and 9).
Do your best to complete all items that apply to your earnings, especially Items 1 through 9.
Always attach copies of your Forms W-2, and Schedule SE if you were self-employed.

Form G-19L (xx-xx)