G-19f (07-04)

Form Approved
OMB NO.3220-0184

In reply refer to

The Railroad Retirement Board (RRB) requires earnings information to determine the amount of
benefits you are entitled to for certain years.
Please furnish earnings information for the years indicated on the next page by completing items 1,
2 and 3. Also complete items 4, 5 and 6 if an "X" appears in the box next to the item. Be sure to
sign and date the form, and provide your telephone number.
If you were employed by someone else, report your total wages before payroll deductions
(even if some of your wages were not covered by Social Security). Furnish copies of your
Forms W-2 for the years indicated.
If you were self-employed, use your income tax returns or business records to get the exact
amount of your self-employment earnings. Furnish copies of Schedule SE, Form 1040, for
the years indicated.
If you or your family have incorporated a business, report your earnings as wages, not self
employment.
If you have any questions about this letter, or if you need additional information, please contact this
office. If you wish to visit the office in person, please bring this letter and your earnings information
with you. Our office is open to the public during normal business hours. If you write to us, please
furnish your daytime telephone number.
Sincerely,

Enclosure: Envelope
SEE NEXT PAGE

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

Form Approved
OMB NO.3220-0184

EARNINGS INFORMATION REQUEST
(EMPLOYMENT FOR HIRE OR SELF-EMPLOYMENT)
Paperwork Reduction and Privacy Act Notice
The Railroad Retirement Board is authorized to collect the following requested information under section 7(b) 6 of the Railroad RetirementAct (RRA). This
information is needed to determine if your earnings affect pa ment of your railroad retirement benefits. Vou are not required to rovide us with the
information requested by this form. However, we may not be a i l e to pay you benefits if you fail to provide us with this information. !he information you
provide may be disclosed for purposes of verificationto the employers you name in this report.
We estimate this form takes an average of 8 minutes to complete, including the time for reviewing the instructions, getting the needed data, and reviewing
the completed form. Federal a encies may not conduct or sponsor, and respondents are not required to respond to, a collection of information unless ~t
displa s a valid OMB number. ?f you wish, send comments regarding the accuracy of pur estimate or an other aspects of this form, including suggestions
for redlcing the completion time, to the Chief of lnformatlon Management, Rallroad Retirement Board. 8 4 1 ~Rush
.
St., Chicago, IL 60611-2092.

1. Did you work for yourself or anyone else in any of the years:
YES - Go to ltem 2
NO - Go to ltem 5

?

?

2. Enter name and address of employer (if self-employed, show "self').

3. Show your total earnings from employment for hire or your total net earnings from self-employment for
each year shown below:

Calendar Year

Total Annual Earnings $

Calendar Year

Total Annual Earnings $

4.

For the calendar year
, show the ross amount earned each month in employment for hire or
the net amount earned each month in se f-employment and the hours worked in each month.

P

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Earn~ngs
Hours

, show the ross amount earned each month in employment for hire or
For the calendar year
the net amount earned each month in se f-employment and the hours worked in each month.

P

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Earnings
Hours

5.

Do you expect to work for yourself or anyone else in

?

YES

NO

If "Yes," furnish estimate of earnings.
6.

OYES q NO

Have you stopped working?
If "Yes," furnish date of last employment.
SIGN AND DATE AT BOTTOM

7. REMARKS:

NOTICE: I certify that the information I am givirlg is true, complete and correct. I understand that criminal
and civil penalties may be imposed on me for false or fraudulent statements.
Sign here:

Telephone Number: (

)

Date: