G-19f (10-07)

Form Approved
OMB NO. 3220-0 184

UNITED STATES OF AMERICA

RAILROADRETIREMENT
BOARD

BIS - INFORMATION
RESOURCES
MANAGEMENT
844 NORTHRUSHSTREET

CHICAGO,
IL 60611-2092
WWW.RRB.GOV

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 daytime 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 under the Social Security Act). 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 net
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 contact us in person, bring this letter and your earnings information with you. If you
contact us in writing, please furnish your daytime telephone number.
Sincerely,

Enclosure: Envelope
SEE NEXT PAGE

Form Approved

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

OMB NO.3220-0184

EARNINGS INFORMATION REQUEST
(EMPLOYMENT FOR HIRE OR SELF-EMPLOYMENT)
Pa erwork Reduction Act and Privacy Act Notices
The Railroad Retirement Board is authorized to collect
following requested information under section 7(b) 6) of the Railroad Retirement Act (RRA). This
information is needed to determine if your earnings affect pa ment of your railroad retirement benefits. (You are not required to rovide us with the
information requested by this form. However, we may not be atle to pay you benefits if you fail to provide us with this information. ?he information you
provide may be disclosed for purposes of verification to the employers you name in this report.

tie

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 lnformatlon unless ~t
displa s a val~dOMB number. ?f you wish, send comments re arding the accuracy of our estimate or any other aspect of this form, including su gestions
for rehcing the completion time, to the Chief of Information 8esources Management, Railroad Retirement Board, 844 N. Rush St., Chicago,
606112092.

a

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

?

?

2. Enter the name and address of your employer and your employer's Federal tax ID or employer
identification number. If self-employed enter an " X in this box 0.

3.

Enter your total gross 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 $

COMPLETE ITEMS BELOW ONLY IF "x"APPEARS IN BOX
4.

q

(n)ON LEFT SIDE OF ITEM

For calendar year
, enter in each month, the gross amount earned in employment for hire or, if
you are reporting self-employment, the net amount earned and the hours worked.
Jan

Feb

Mar

Apr

May

Jun

Jul

Ayg

Sep

Oct

Nov

Dec

Earnings
Hours

q

For calendar year
, enter in each month, the gross amount earned in employment for hire or, if
you are reporting self-employment, the net amount earned and the hours worked.
Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Earnings
Hours

5.

q

Do you expect to work for yourself or anyone else in

?

DYES

ON0

UYES

ON0

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

q

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

7. REMARKS:

NOTICE: 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 or fraudulent statements.
Signature

I Telephone Number

I Date