Form G-212 (proposed) G-212 (proposed) 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 complete Items I t h r o u g h 7
on the next page then sign and date the Certification Statement in Item 8.
Be sure to return both pages of this form, along with a copy of your latest public service
pension award or adjustment letter, within 15 days of the date of this letter.
If you have any questions about this letter or need additional information, contact our office located
. The telephone number is
at

Enclosure
Envelope
PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICES
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 Resources
Management, Railroad Retirement Board, 844 North Rush.Street, Chicago, IL 60611-2092.

Form Approved
OMB NO.3220-0136

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

I

Enter the effective date of this amount.

I
Day

Mo.

I

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

Mo.

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

Mo.

Year

I

I
Day

Year

I

I
Day

Year

n ~ e s - ( G O to Item 7)

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

No-(Go

I

Enter the amount of the lump sum and the period it
covered.

I From:
$

I
Mo.

To:

to Item 8)

I
Day

Year

I'
IMo. Day Year

Certification Statement
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 know~edge,the information 1hive given is true, complete, and correct.
Signature
Date
I

Print Name

Daytime Telephone Number

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