Form G-19L (03-11) G-19L (03-11) Annual Earnings Questionnaire for Annuitants in Last Per

Fonn Approved
OMB No. 3220-0179

UNITED STATES OF AMERICA

RAILROAD RETIREMENT BOARD

OFFICE HOURS: 9:00 AM TO 3 :30 PM
MONDAY THROVGH FRIDAY EXCEPT FEDERAL HOLIDAYS

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

FACSIMILE NUMBER: X-XXX-XXX-XXXX

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, non railroad 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 you were
self-employed in . Below are some guidelines and instructions that will help you complete
the questionnaire.
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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.
The total earnings you report in Items 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.
Remember to provide an estimate of your earnings for all months in calendar year
in Items 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.

Fonn G-19L (03-11)

UNITED STATES RAILROAD RETIREMENT BOARD

•

2

If you have questions about how to complete 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 questionnaire and any other information you have about your claim.
Before completing the enclosed form, please read "Important Notices" below.
Sincerely,

Enclosures
Annual Earnings Questionnaire
Return Envelope

IMPORTANT NOTICES
Paperwork Reduction Act and Privacy Act Notices
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, 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
Information Resources Management, Railroad Retirement Board, 844 N. Rush Street, Chicago, IL 60611­
2092.

Computer Matching and Privacy 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. Information 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 (03-11)

United States of America
Railroad Retirement Board

ANNUAL EARNINGS QUESTIONNAIRE

PARTB

PART A
COMPLETE THIS PART FOR EARNINGS
THAT ARE FROM YOUR LAST
PRE-RE1-IREMENT (NON RAILROAD)
EMPLOYER

ADDRESS

PARTC

COMPLETE THIS PART FOR NET
SELF-EMPLOYMENT EARNINGS

LAST PRE-RETIREMENT
EMPLOYER

i

EARNINGS IN MONTH

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

:

4. TOTAL :

$0.00

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

I

I

EARNINGS IN MONTH

$0.00

5. EARNINGS ESTIMATE FOR
NET SELF-EMPLOYMENT: $
6. IF NO LONGER EMPLOYED, SHOW THE
DATE YOUR WORK ENDED:
YEAR
DAY I
I MO.
DATE I

7. TOTAL :

$0.00

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

I

I

I
Do your best to complete all items that pertain to your earnings, especially Items 1 through 9. Be sure to enclose copies of your
Forms W-2 for and a copy of Schedule SE if you were self-employed.

I CERTIFY THAT THE INFORMA TION I AM GIVING IS TRUE, COMPLETE, AND CORRECT. I UNDERSTAND THAT CRIMINAL AND
CIVIL PENALTIES MA Y BE IMPOSED ON ME FOR FALSE AND FRAUDULENT STATEMENTS.
SIGNA TURE

DA TE

Daytime Telephone Number
(In case we have questions about your responses.)

Area Code

II

TelThone Number

I

-I I I

MAIL YOUR COMPLETED QUESTIONNAIRE TO:
U.S. RAILROAD RETIREMENT BOARD

Form G-19L (03-11)

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 B - 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 1, , do not complete Part B.
PART C - Use Part C to report work and earnings that are not reported in Parts A or B. If you
were age 70 or older as of January 1, , do not complete Part C.

Follow these instructions for completing 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 and/or 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 (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 (03-11)