G-19L; Annual Earnings Questionnaire

In reply refer to

XX
Date of Birth:
Work Deduction Amount: $
Annual Earnings Questionnaire
Our records show that part of your annuity is being reduced because you are working for your last
pre-retirement, nor~railroademployer. In order for us to determine if we withheld the correct
amount, please complete the questionnaire on the next page and return it to us. Be sure to
provide a monthly breakdown of your earnings. If your annuity has been recently adjusted to
remove work deductions, please disregard this notice.
The questionnaire is divided into three parts. Following the instructions on the enclosed Form
G-19L.1, you should complete the parts of the questionnaire corresponding to the type of
. Attach a copv of your
Forms W-2 and a copv of vour Schedule
employment you had in
SE if vou were self-employed in . Below are some guidelines and instructions that will help you
complete the questionnaire.
9 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.
9 The total earnings you report in ltems 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.
9 Remember to provide an estimate of your earnings for calendar year 1 in ltems 2, 5, and 8.

Be sure to sign and date the form in the spaces provided. Attach your Forms W-2 or Schedule SE.
Sincerely,

Enclosures
Form G-19L. 1
Return Envelope

United States o f America
Railroad Retirement Board

1

Form Approved
OMB NO.3220-0179

PART A
COMPLETE THlS PART FOR EARNINGS
THAT ARE FROM YOUR LAST
PRE-RETIREMENT(NONRAILROAD)
EMPLOYER
LAST PRE-RETIREMENT
EMPLOYER

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

COMPLETE THlS PART FOR NET
SELF-EMPLOYMENT EARNINGS

)

ADDRESS

MONTH

PART C

PART B

EARNINGS IN MONTH

NET SELF-EMPLOYMENT
TYPE OF WORK

OTHER POST RETIREMENT
EMPLOYER

ADDRESS

ADDRESS

MONTH

EARNINGS IN MONTH

JANUARY

JANUARY

EARNINGS IN MONTH

MONTH
JANUARY

I MARCH
I APRIL

I
I

I MARCH
1 APRIL

I
I

1 MARCH
I APRIL

I
I

1
1

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I

I

I

I

I

1

I
I
I

I
I
I

I

I

MAY

MAY

MAY

JUNE

JUNE

JUNE

JULY

JULY

JULY

AUGUST

AUGUST

AUGUST

I SEPTEMBER
I OCTOBER
I NOVEMBER

(

I

I OCTOBER
I NOVEMBER

I
I

I SEPTEMBER
I OCTOBER
/ NOVEMBER

I

1

1

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DECEMBER

I

1. TOTAL :
$0.00
2. 1 EARNINGS ESTIMATE FOR
THIS EMPLOYMENT: $
3. IF NO LONGER EMPLOYED. SHOW THE
DA-rE YOUR WORK ENDED:

1
1

4. TOTAL :
$0.00
5. 1 EARNINGS ESTIMATE FOR
NET SELF-EMPLOYMENT: $
6. IF NO LONGER EMPLOYED. SHOW THE

1

I
1

DATE
I

I

I

I

DECEMBER

1 7. TOTAL

DA-rE YOUR WORK ENDED:

DATE
I

DECEMBER

:
$0.00
8. 1 EARNINGS ESTIMATE FOR
THIS EMPLOYMENT: $
9. IF NO LONGER EMPLOYED. SHOW THE
DATE YOUR WORK ENDED:
DATE

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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.

To avoid penalfies, o u musf refurn fhis quesfionnaire wifhin 30 da s o f fhe dafe of the form. If you need more fime, lef us know a s
soon a s possible.
e can allow addifional fime if y o u have specia circumsfances.
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.

Y

&

DA TE

SIGNATURE
Daytime Telephone Number (optional)
(In case we have quesfions abouf your responses.)

Area Code

@

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

Telephone Number

-

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