Form RI 92-22 RI 92-22 Annuity Supplement Earnings Report_MarkUp

Form Approved:
OMB No. 3206-0194

2018 Annuity Supplement
Earnings Report
Claim Number

U.S. Office of Personnel Management
Retirement Surveys & Students Branch
1900 E Street, NW
Washington, DC 20415-0001
DOB

Date

Case Name

Complete and return this form if your allowable earnings were more than $17,040 or if your FERS
Annuity Supplement was reduced in a previous year.
The annuity supplement part of your FERS benefit is subject to an earnings test similar to the one applied to Social
Security Benefits and uses the same exempt amount, as required by law in 5 U.S.C. Section 8421a. Your annuity
supplement will be reduced $1.00 for every $2.00 by which you exceed the exempt amount ($17,040 for 2018).
By law, this reduction is effective July 1, 2019. We apply the test only to earnings you received in 2018 after
retirement and after you reach the Minimum Retirement Age (MRA). Full-Time Air Traffic Controller (ATC)
Instructors are excluded. The exempt amount for 2019 is $17,640.
Please answer the following questions and return this survey form before May 15, 2019, or as soon as you
know the exact amount of your allowable earnings.
1. Is your annuity supplement currently reduced because you reported excess earnings in a previous year?
Yes (Please skip directly to question 4 and report your earnings for 2018.)
No (Please continue to question 2.)

2. Did you have any earnings in 2018 after retirement? Note: Only a full-time contracted ATC Instructor earnings
are exempt from being reported.
Yes (Please continue to question 3.)
No (Do not return this form. You may throw it away or keep it for your records.)

3. Refer to the chart below to find out what you should report based on your year of birth.
Year of Birth
1957 - 1961
1962

What You Should Report
Report all 2018 earnings after retirement, if your earnings were more than $17,040.
Report all 2018 earnings after retirement and after you turned 56 years old, if your
earnings were more than $17,040.

4. What were your earnings in 2018 after retirement?
Note: Exclude ATC Instructor full-time wages.

Warning:

.
Dollars

Cents

Your earnings for 2018 will be verified through a computer match with the Social Security Administration's earning file.
Any intentionally false statement or willful misrepresentation is punishable by fine, imprisonment, or both (18 U.S.C. 1001).

Signature

Previous editions are not usable

Daytime telephone number

Email address

Date (mm/dd/yyyy)

RI 92-22
Revised March 2019

Instructions:
1.

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3.

4.
5.

Read the section below entitled: How To Determine The Amount of Earnings You Should Report. If you have questions,
please telephone (202) 606-0249 Monday through Friday between 9:30 AM and 5:00 PM, Eastern Time. If you use TTY
equipment, call 1-855-887-4957.
Provide clear and legible information. Do not detach any portion of this form.
Fill in, sign, and mail this report in the envelope provided, or mail the report to: U.S. Office of Personnel Management,
Retirement Surveys and Students Branch, FERS Annuity Supplement Survey, 1900 E St., NW, Washington, DC
20415-0001 or fax your response to (202) 606-0022.
Retain copies of evidence supporting your claimed earnings in the event you are required to furnish documentation of
earnings.
Do Not include your annuity payments from OPM or any 2018 ATC Instructor full-time wages. Include, as earnings, all
income from wages and self-employment that you actually received plus deferred income you actually earned during 2018.

How To Determine The Amount of Earnings You Should Report
Include as earnings:

Do not include as earnings:

- All wages from employment covered by social security.
- All cash pay for agricultural work, domestic work in a
private home, service not in the course of your employer's
trade or business.

- ATC Full-time Contracted Instructor pay excluded
as of 1/1/2018 through 12/30/2018.
- Pensions or annuities paid as retirement income, including
your FERS benefit or any benefits received as a survivor.

- All pay, cash or non-cash, for work as a home worker for a
non-profit organization, no matter the amount. (The Social
Security $100.00 tax test does not apply.)

- Monies which you earned before entitlement for annuity
supplement and/or received for annual leave upon
retirement. This includes separation incentives.

- All pay for work not covered by Social Security, if the
work is done in the United States, including pay for:
* Family employment,
* Work as a student, student nurse, intern,
newspaper and magazine vendor,
* Work for States or foreign governments or
instrumentalities, and
* Work covered by the Railroad Retirement Act.

- Unemployment compensation.

Regardless of what income is called or who receives it, if
it is actually wages for services you performed or net
earnings from self-employment you secured, it must be
included in applying the earnings test.

- Gifts, insurance proceeds, inheritances, scholarships,
alimony, capital gains, net business losses, prize winnings.
- Payments-in-kind for domestic service in the employer's
private home, for agricultural labor, for work not in the
course of the employer's trade or business, or the value of
meals and lodging.
- Rentals from real estate which cannot be counted in
earnings from self-employment because, for instance, you
were not a real estate dealer.
- Interest and dividends not resulting from trade or business.
- Pay for Veteran's training and for jury duty.
- Payments by an employer which are reimbursement
specifically for your travel expenses and which are so
identified by the employer at the time of payment and/or
reimbursement or allowance for moving expenses, if they
are not counted as wages for Social Security purposes.

For more information about the Annuity Supplement, refer to Information for FERS Annuitants, RI 90-8. Information begins in
Part B. If you would like a copy of this booklet, call the Retirement Information Office toll free at 1-888-767-6738; (TTY)
1-855-887-4957; or write: U.S. Office of Personnel Management, Post Office Box 45, Boyers, Pennsylvania 16017. This booklet
is also available on the OPM website at www.opm.gov/retirement-services/publications-forms/pamphlets/RI90-8.pdf. Remember
your annuity supplement will stop at the end of the month you reach age 62 or the month before you become entitled to social
security benefits, whichever is earlier.
Privacy Act Statement
Pursuant to 5 U.S.C.§ 552a(e)(3), this Privacy Act Statement serves to inform you of why OPM is requesting the information on the form. Authority: OPM is
authorized to collect the information requested on this form by 5 U.S.C., Chapter 84, Section 8421 and 5 CFR 842.504. Purpose: OPM is requesting this
information in order to determine your eligibility to continue receiving the annuity supplement and the amount of the supplement. Routine Uses: The information
on this form may be shared externally as a "routine use" to other Federal agencies and third-parties when it is necessary to determine your eligibility. For example,
OPM may share your information with other Federal, state, or local agencies and organizations in order to determine benefits under their programs, to obtain
necessary information for an eligibility determination, or to report income for tax purposes. OPM may also share your information with law enforcement agencies
if it becomes aware of a violation or potential violation of civil or criminal law. A complete list of the routine uses can be found in the OPM/CENTRAL 1 Civil
Service Retirement and Insurance Records system of records notice, available at www.opm.gov/privacy. Consequences of Failure to Provide information:
Providing this information is voluntary; however, failure to supply accurate information may result in suspension of your annuity benefit.

Public Burden Statement

We estimate providing this information takes an average 15 minutes per response, including the time for reviewing instructions, getting the needed data, and
reviewing the requested information. Send comments regarding our estimate or any other aspect of this form, including suggestions for reducing completion time,
to the United States Office of Personnel Management, Retirement Services Publications Team, (3206-0194), Washington, DC 20415-0001. The OMB Number,
3206-0194, is currently valid. OPM may not collect this information, and you are not required to respond, unless the number is displayed.
Reverse of RI 92-22
Revised March 2019