G-212 (05-04) Public Service Pension Monitoring Questionnaire

Form Approved
OMB NO.3220-0136

In reply refer to

We are required by law to reduce the tier 1 portion of your railroad retirement annuity because you
are currently receiving a public service pension. We need to verify the current amount of your
public service pension to ensure we are paying you correctly. Please answer the following
questions and return both pages of this form to us, along with a copy of your latest public service
pension award or adjustment letter. If you need assistance, please let us know.

1. Enter the name of the agency or organization that pays
your public service pension.
2. Enter the current amount of your public service
pension. (This amount should be after reduction for
early retirement or election of a survivor benefits
option, but before deductions for health insurance,
Medicare premium reimbursement, bonds, tax
withholding and other allotments.)

3. Enter the effective date of this amount.
4.

Enter the date of the first payment you received for this
amount.

5. Enter the effective date of the next cost of living increase
you expect to receive. If you do not receive cost-ofliving increases, enter "None."

6. Was your cost of living increase paid in a lump sum?

$

I

I

Day

Mo.

I

1

Day

Mo.
I

Mo.
Yes
No

Year
Year
I

Day

Year

(Go to Item 7)
(Skip Item 7)

7. If Yes, what was the amount of the lump sum and what
period did it cover?

$

From
I
To -1-1-

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***PLEASE ATTACH A COPY OF YOUR LATEST PSP AWARD or ADJUSTMENT LETTER***

I understand that civil and criminal penalties may be imposed on me for false or fraudulent
statements or for withholding information to cause payment of benefits by the RRB. I affirm that, to
the best of my knowledge, the information I have given is true, complete, and correct.
SIGNATURE
PRINT NAME

DATE
DAYTIME
PHONE

)

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PAPERWORK REDUCTION AND PRIVACY ACT NOTICE
The Railroad Retirement Board (RRB) is authorized to collect this information under section 7(b)(6) of the Railroad Retirement
Act. This information is needed to determine whether any public service pension that you are currently receiving will affect your
railroad retirement benefits. You are not required to provide the information requested by this form. However, your failure to
provide us with the requested information may result in our being unable to pay you benefits. The information you provide may
be disclosed for purposes of verification to your former public service employer(s).
We estimate it takes an average of 15 minutes to complete this form, including the time to review the instructions, get the
needed data, and review 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 Management, Railroad Retirement Board, 844 North Rush Street, Chicago, IL 60611-2092.