G-19L Annual Earnings Questionnaire

PROPOSED
Form Approved
OMB No. 3220-0179

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD
844 NORTH RUSH STREET
CHICAGO, ILLINOIS 60611-1275

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

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

In reply refer to
Work Deduction Amount: $
You may have stopped working, but our records show that part of your annuity is being reduced for
work for your last pre-retirement, non-railroad employer. In order for us to determine if we withheld
the correct amount or whether we should stop withholding, please complete the enclosed
questionnaire and return it to us. Be sure to provide a monthly breakdown of your earnings. If
your annuity was recently adjusted to remove work deductions, do not complete the form. Instead,
sign the form and write “Work Deductions Removed” beneath your signature. Return the
questionnaire using the enclosed return envelope.
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.
➢ 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.

G-19L (XX-XX)

UNITED STATES RAILROAD RETIREMENT BOARD - 2
If you have questions about the questionnaire or how to complete it, contact us at the
address shown at the bottom of the enclosed questionnaire or call us at 312.469.2135. For
all other questions about your annuity, contact your local Railroad Retirement Board office at
877.772.5772.
Before completing the enclosed form, please read “Important Notices” below.

Director of Program Evaluation and
Management Services

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:
Associate Chief Information Officer for Policy and Compliance, Railroad Retirement Board, 844 N. Rush
Street, Chicago, IL 60611-1275.
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.

G-19L (XX-XX)

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0179

ANNUAL EARNINGS QUESTIONNAIRE

Error! Reference source not found.
PART A
COMPLETE THIS PART FOR EARNINGS
THAT ARE FROM YOUR LAST
PRE-RETIREMENT (NONRAILROAD)
EMPLOYER

PART B

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

COMPLETE THIS PART FOR NET
SELF-EMPLOYMENT EARNINGS

LAST PRE-RETIREMENT

NET SELF-EMPLOYMENT

OTHER POST RETIREMENT

EMPLOYER

TYPE OF WORK

EMPLOYER

ADDRESS

ADDRESS

ADDRESS

EMPLOYER IDENTIFICATION NO. (EIN)

MONTH

EMPLOYER IDENTIFICATION NO. (EIN)

EARNINGS IN MONTH

MONTH

EARNINGS IN MONTH

MONTH

JANUARY

JANUARY

JANUARY

FEBRUARY

FEBRUARY

FEBRUARY

MARCH

MARCH

MARCH

APRIL

APRIL

APRIL

MAY

MAY

MAY

JUNE

JUNE

JUNE

JULY

JULY

JULY

AUGUST

AUGUST

AUGUST

SEPTEMBER

SEPTEMBER

SEPTEMBER

OCTOBER

OCTOBER

OCTOBER

NOVEMBER

NOVEMBER

NOVEMBER

DECEMBER
1. TOTAL :
2.

DECEMBER
$

: EARNINGS ESTIMATE FOR

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

DECEMBER

4. TOTAL :
5.

EARNINGS IN MONTH

7. TOTAL :

$

EARNINGS ESTIMATE FOR

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

8.

$

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 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 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.

DATE

SIGNATURE

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



Area Code

Telephone Number

-

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

G-19L (XX-XX)

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
2020. 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.

G-19L (XX-XX)