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pdfUnited States of America
Railroad Retirement Board
Form Approved
OMB No. 3220-0187
Continuing Disability Report
Paperwork Reduction ActlPrivacy Act Notice
The Railroad Retirement Board's (RRB) authority for requesting this information is Section 7(b)(6) of the Railroad
Retirement Act (RRA). The information requested on this report is needed to determine your continuing entitlement to
disability benefits under the RRA and the correct amount of such benefits. If you fail or refuse to furnish information
which is necessary to determine your continuing entitlement to benefits, non-payment of benefits may result (as
explained in Section 2(a) of the RRA).
The information on this form may be disclosed by the RRB to another person or governmental agency only with respect
to railroad retirement benefits and only to comply with Federal law requiring the exchange of information between the
RRB and another agency.
We estimate this form takes an average of 35 minutes to complete, including the time for reviewing the instructions, getting the
needed data, and reviewing 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 completion time, to Chief
of lnformation Resources Management, Railroad Retirement Board, 844 North Rush Street, Chicago, Illinois 60611-2092.
General Instructions
Type or print all answers legibly in ink. If you need more space than is provided to answer a question, use Section 6 for
this purpose. If you do not know the answer to a question, print "Unknown" in the space provided for the answer.
Due to the complexity of ltems 14a and 25a, regarding "Expenses," contact the Railroad Retirement Board if you need
assistance.
If you are completing this form on behalf of someone else, you must answer each question as it applies to the applicant.
Some items in this application will not apply to you so you will not need to answer them. Based on your answers
to a question, you may be told to skip to another item number or section. Follow the instructions that tell you to
"Go to" another item. They are designed to help you move through the report quickly and provide only necessary
information. If no "Go to" instructions are given, answer the next item in order. Do not skip any items unless
directed to do so.
,
If you are an employee, your annuity cannot be paid for any month in which you earn over $730.00. Please notify the
nearest office of the RRB if your earnings exceed $730.00 a month.
1 i i
Month
THE PERIOD COVERED IN THIS REPORT IS
Yyr
;D
TO PRESENT
ldentifying lnformation
Check the information provided for ltems 1 through 5 for accuracy.
b If the information is correct, go to Section 3.
b If the information is not correct, cross out the incorrect information and enter the correct information above it.
b If the information is missing, fill it in.
ldentifying 1 Employee's Name
Information
2 Employee's Social Security Number
3 Employee's Railroad Retirement Claim Number
4 Your Name
5 Your Social Security Number
Information about Work for an Employer
6 Have you worked for an employer (railroad or
Workfor
Employer
,
nonrailroad) during the period shown in Section 1,
above?
b
Q Yes b Go to Item 7
No
b Go to Section 4
Form G-254 (XX-XX) Destroy Prior Editions
Last
Work
(7
for
Enter information about your employer(s) in Items 7a-c below. (Note: If you have had more than one
employer during the period covered in this report, enter information about your last employer first.)
a (1) First Employer's Name
Employer
1
(2) Employer's Address
=
(3) Employer's Telephone Number (Include Area Code)
(
)
(4) TitlelName of your job
(5) Describe your job duties. (Include weights lifted and how frequently lifted; hours spent standinglsitting;
frequency of bendinglstoopinglclimbing, etc.)
I
1 (7) Days Worked Per Week
(6) Monthly Rate of Pay
$
(9) Hourly Rate of Pay
$
(8) Hours Worked Per Day
(IOa) Date Work
Began b
1 Month 1
Day
1
Year
(lob) Date Work
Ended b
Month
1
I
Day
1
Year
1
(11) If work has ended, explain why.
Second
b (1) Second Employer's Name
Last
Employer
(2) Employer's Address
*
(3) Employer's Telephone Number (Include Area Code)
i
)
(4) TitlelName of your job
(5) Describe your job duties. (Include weights lifted and how frequently lifted; hours spent standinglsitting;
frequency of bendinglstoopinglclirnbing,etc.)
(7) Days Worked Per Week
(6) Monthly Rate of Pay
I
(8) Hours Worked Per Day
(9) Hourly Rate of Pay
@
I
(10a) Date Work
Began b
Month
Day
Year
I
I
(11) If work has ended, explain why.
I
Form G-254 (XX-XX)
Page 2
(lob) Date Work
Ended b
Month
Day
Year
7
Third
Last
Employer
C
(1) Third Employer's Name
(2) Employer's Address
(3) Employer's Telephone Number (Include Area Code)
=
I
(
)
1
(4) TitleIName of your job
I
(5) Describe your job duties. (Include weights lifted and how frequently lifted; hours spent standinglsitting;
frequency of bendinglstoopinglclimbing, etc.)
I
1 (7)
(6) Monthly Rate of Pay
Days Worked Per Week
$
(8) Hours Worked Per Day
(9) Hourly Rate of Pay
$
(10a) Date Work
Began b
i
Month
Day
Year
Month
(lob) Date Work
Ended b
Year
Day
(11) If work has ended, explain why.
I
Earnings 1 8
Special 9
Earnings
(If you need more space to list employers, continue in Section 6)
List any months during the period shown in Section 1, in which you earned more than $730.00.
a Have your earnings included any other payment,
such as tips, bonuses, child care, sick or vacation
pay, free meals, room or transportation?
'
a Yes
No
b Go to ltem 9b
,
Gotoltemlo
b List below type of other payment(s) received, estimated dollar value, frequency of payment,
and employer's name.
-
or Less
-
and then stop work
because of your disabling condition?
Continue
or Return
to Work
11 Did you continue in or return to the same work
Special
Employment
12 a Are (were) you employed by a friend or relative
duties, hours, and pay as you had before your
disabling conditions began?
or through a special training or rehabilitation
program?
Page 3
'
'
'
-
-
a Yes
-
-
-
No
a Yes
No
b Go to ltem I 4
,
Gotoltemll
a Yes b
O N o
Go to ltem 12b
,Gotolteml3
Form G-254 (XX-XX)
Special
12
Employment
(Continued)
-
Different
Job
Duties
b Explain how and why you were hired.
-
-
-
-
-
-
-
13 a Have your job duties differed from those of other
workers with the same job title?
'
Yes b Go to Item 13b
a No
b Gotolteml4
b Check all that apply them go to ltem 13c.
a 1. Shorter hours
a 4. Extra help given
0
0
2. Different pay scales
a 5. Lower production
0
3. Fewer or easier duties
a 6. Lower quality
7. Other - Explain in ltem 13c
c Explain in more detail, each selection made in ltem 13b. Note: For each explanation, include the item
number at the beginning of the answer. Also, if you have had more than 1 employer, identify the
14 a Do you have any impairment-related expenses
Impairmentthat are necessary for you to work? (For example,
Related
prescription medications, medical services, attenExpenses
dant care, medical devices, equipment, prosthesis,
'
or similar items or services.)
-
-
b List each impairment-related expense and provide a receipt.
Form G-254 (XX-XX)
Page 4
a Yes
a No
b Go to ltem 14b
b Go to Section 4
Information about Self-Employment
Only complete Section 4 if you were self-employed duriqg the period shown in Section 1. This would include selfemployment for a family owned, controlled or managed business, including a business operated, managed, or owned by
you, a family member, friend or close associate, whether for pay or not, and without regard to how the business is organized (e.g., sole proprietorship, partnership, corporation, LLC, etc.). Otherwise, go to Section 5.
15 a Enter the name and address of the business.
Self-
mwrn
0
0
b Did you work 40 or more hours a month?
c Check the box that describes the nature of the
business.
b
Yes
No
a Farm
0
Won-Farm
0
Sole Owner
d Enter the primary product or service.
e Check the box that describes the business in terms
of arrangement and/or ownership.
I
b
0
a Farm Tenant
[7 Farm Landlord
0
f (1) Have you received anything of value in lieu of salary
or wages for any work that you performed?
( 2 ) Describe what you have received of value in lieu of
a salarv or waaes.
Partnership
a Corporation
LLC
Yes - Go to Item 15f(2)
No-Gotoltem15g
b
g Enter, below, the requested information about your monthly self-employment income for each month
during the period shown in Section 1, starting with the latest month. If you need more space, continue
in Section 6 or attach a separate piece of paper.
Month
1
Year
Hours Worked
in Month
Gross Income
Net Income
h Did you become a corporate officer, own or operate a corporation, or perform
work for any corporation at anytime (including a corporation owned by a family
member or friend) whether for pay or not, since the date listed in Section I ?
b
a Yes
0
No
i Prior to the period shown in Section 1, what did you do in the business in terms of management
decisions, responsibilities, hours, production and services?
-
j Was this business your sole livelihood before the
period shown in Section I ?
Yes
0
Page 5
No
Form G-254 (XX-XX)
-- -
Self15
Employment
(Continued)
-
-
-
-
k Describe the duties you perform on an average work day. Include any changes in your business
because of your disabling condition, such as reduced business hours, lower volume, fewer
acres under cultivation, etc.
16 a Because of your disabling condition, do you need
additional help to perform your usual duties?
1
-
'
a Yes
No
b Go to Item l 6 b
bGotolteml7
b Enter the number of assistants you have.
a
c Check the box that describes when you receive assistance.
0
By the day
By the'week
By the month
d Enter how many hours your assistant(s) spends helping you? (Show if per day, week, or month.)
Form G-254 (XX-XX)
Page 6
Assistant
(Continua
16 f Does your assistant(s) get paid?
b
0
Yes t Go to ltem l 6 g
0 No
.t Go to ltem l 6 h
g Enter the amount your assistant(s) gets paid. (Show if per hour, day, or month.)
h Is your assistant(s) related to you?
b
0 Yes
0 No
t Go to ltem l 6 i
t Go to ltem l 6 j
'
0 Yes
0 No
t Go to Item 17b
t Go to Item 18
i Enter the relationship of your assistant(s) to you.
j Explain why you need additional help.
Decision:
17 a Have you made management decisions during
the period shown in Section I ?
b Describe the type of management decisions you made, how much time you spent making
them, and any changes that have taken place.
-
Page 7
Form G-254 (XX-XX)
18 Did you start your business after your disabling
condition began?
Began
19 Did you receive any special assistance from an
agency or other source in setting up your business?
1
-
-
-
-
-
-
-
-
a Yes
'
'
'
•
a Yes
No
-
20 Do you still receive this special assistance or have
additional special services been supplied?
No
b Go to Item I 9
Go to Section 5
b Go to Item 20
›
Go to Item 22
-
IJ
0
Yes b Go to Item 21
'
0
Yes b Go to ltem 23
IJ
No
b
0
0
Yes b Go to ltem 25b
No
,
Go to Item 22
21 Describe the continued assistance or special services.
Business 2
Expenses
2 Are there any normal business expenses paid for or
furnished by another person or organization (for
example, free space or utilities)?
t Go to Section 5
124 Explain why and by whom these expenses were furnished.
I
25 a Do you have any impairment-related expenses
RelatedExpenses
that are necessary for you to work? (For example,
prescription medications, medical services, attendant care, medical devices, equipment, prosthesis,
or similar items or services.)
b List each impairment-related expense and provide a receipt.
-
Form G-254 (XX-XX)
Page 8
-
-
No
b Go to Section 5
Information about Your Condition before Full Retirement Age
Condition
Before
Full Retirement Age 1
26 a Describe your present medical condition.
-
-
p
p
p
p
p
b Describe any change (better or worse) in your condition, if any, during the period shown in Section 1.
If none, enter "None."
1
c Does your condition prevent you from
working now?
d Have you received any treatment or care for your
condition during the period shown in Section I?
(
Yes b Go to ltem 26d
b
a
No
b
a
Yes b Go to ltem 27
No b Go to Item 28
b Go to ltem 26e
e Explain why your condition does not prevent you from working now.
27 a (1) Enter the name and address of the most recent source of treatment or care (doctor, hospital, or clinic).
Treatment
or Care
(2) Enter the Patient Number (if applicable).
(3) Enter the telephone number of the treatment source (include area code).
I
e
(
1
(4) Enter the date(s) you were treated.
(5) Describe the condition(s) for which you received treatment.
(6) Describe the treatment.
I
Page 9
Form G-254 (XX-XX)
Treatment 27
or Care
(Continued)
b (1) Enter the name and address of the second most recent source of treatment or care (doctor, hospital, or clinic).
( 2 ) Enter the Patient Number (if applicable).
(3) Enter the telephone number of the treatment source (include area code).
I
=
(
)
(4) Enter the date(s) you were treated.
(5) Describe the condition(s) for which you received treatment.
I
(6) Describe the treatment.
(If you need more space to list sources of care, continue in Section 6)
Medication 28
a Are you taking medication or receiving
Yes t Go to ltem 28b
treatment now?
No t Go to ltem 29
b Enter the medication or treatment below. Note: If you are taking prescription medication, furnish
the name or type of medication and dosage from the label. (For example, Penicillin, 1.5 gram
tablet, 3 times a day.)
Form G-254 (XX-XX)
Page 10
Restriction
of
Activities (
I
29 a Has your doctor restricted your activities?
c Is the name of the doctor who restricted your activities
different from the name of the doctor(s) shown in ltem
27a or Item 27b?
b
Doctor's Name:
Yes b Enter doctor's name then
go to ltem 30
No
0
Yes b Go to Item 30b
a
No
b Go to ltem 30
b Go to Item 31
Month
Day
Year
return to work.
Doctor's Name:
I
b Go to Item 30
0
b Enter the date your doctor said you could
c Is the name of the doctor who told you that you are
able to return to work different from the name of the
doctor(s) shown in ltem 27a or ltem 27b?
Activities
a
to return to work?
I
IVo
b Describe the restriction(s).
30 a Has your doctor told you that you are able
Return
to Work
Yes b Go to ltem 29b
b
0
b
Yes b Enter doctor's name then
go to Item 31
No b Go to ltem 31
31 Check the one box after each activity listed below that best describes your ability to do that activity.
"Yes"
"No"
"Hard"
1
-
Means you can do the activity without help.
Means you cannot do the activity even with help.
Means the activity is hard for you to do, or that you need help. Explain each "Hard" answer.
Activitv
I yes 1
No l ~ a r d l
10
0 0
Ex~lanation
Walking
1
Eating
I
Bathing
I
1
Dressing, tying shoes,
combing hair, etc.
0 0 O~
Other bodily needs
0
Indoor chores
iooking, cleaning, etc.)
Outdoor chores
(shopping, yardwork, etc.)
1
i
Driving a motor vehicle
0
1 1 1 1
10
0 0 0
0'0
I0l00l
Using public
transportation
I
Talking to and dealing
with other people
0 0 O~
Page 11
Form G-254 (XX-XX)
32 a During the period shown in Section 1, have you
Rehabilita
tion
Agency
received services, such as training, counseling, placement, medical examination, treatment, etc., from or
through a state vocational rehabilitation agency?
Q Yes b Go to Item 32b
0 No b Go to Item 33
b Enter the Name, Address, and Telephone Number of your vocational rehabilitation counselor.
(
c Enter the date(s) you received services.
d Describe the services you received.
33 a During the period shown in Section 1, have you
Other
Agencies
received services such as training, counseling, placement, medical examination, treatment, etc., from
other agencies, such as VA, Worker's Compensation,
Welfare, etc.?
b Enter the Name, Address, and Telephone Number of the agency.
Tf
(
)
c Enter your claim number at that agency.
(
d Enter the date@)you received services.
I
Form 6-254 (XX-XX)
Page I 2
Q Yes b Go to ltem 33b
0
No b Go to Item 34
Other
33
Agencies
I
Education 34
e Describe the services you received.
a Have you attended school (trade, vocational, or
academic) during the period shown in Section I?
0
0
Yes b Go to Item 34b
No
b Go to Section 7
b Enter the Name, Address, and Telephone Number of the school.
d Enter the dates you attended the school.
Continuation and Remarks
Continua- 35 This section is to be used for the continuation of answers to other items. Be sure to include the
tion and
item number at the beginning of the answer you wish to continue. You may also use this section
Remarks
to enter additional information that you feel may be important to include.
(Continue on next page)
Page 13
Form G-254 (XX-XX)
tion and
Remarks
(Continued)
-
-
(If you need more space, attach a separate sheet of paper)
I
Form G-254 (XX-XX)
Page 14
Authorization and Certification
AulhorMon 36
and
Certification
Will this report be signed by a guardian or any
other person representing the beneficiary?
b
a Yes
a No
b Read Note then go to ltem 37
b Go to Item 37
Note: If answered "Yes,"your guardian or representative must sign this report in ltem 37.
I understand that civil and criminal penalties may be imposed upon me for false or fraudulent statements,
or for withholding information to misrepresent a fact or facts material to determining a right to benefits
under the Railroad Retirement Act. I aftirm that to the best of my knowledge, the information I have provided
on this form is true, complete, and correct.
I have received the appropriate application booklets, RB-Id, Employee Disability Benefits, and RB-9,
Employee and Spouse Events That Must Be Repotted. I understand that I am responsible for reporting
any events that would affect my annuity as explained in these booklets.
I authorize the Railroad Retirement Board to secure any information from the Social Security Administration
which is required to determine my continuing entitlement to benefits under the Railroad Retirement Act.
Signature b
Date
b
Daytime Telephone Number (Include Area Code)
138
1
If this certification is signed by mark ("X") in ltem 37, two witnesses who know the person signing must
sign below, giving their full addresses and daytime telephone numbers.
a. Signature of Witness
Address (Number and Street)
City, State, and ZIP Code
1
Daytime Telephone Number
b
I Area Code I
Tele~honeNumber
Area Code
Telephone Number
b. Signature of Witness
Address (Number and Street)
City, State, and ZIP Code
Daytime Telephone Number
b
Page 15
Form G-254 (XX-XX)
How to Return Your Report
Before you return your report, check to make sure that:
b
b
b
Every question that applies to you has been answered.
You have entered "Unknown" in any answer space for which you were unable to answer a
question.
You have signed and dated the report.
When you received your report, you should also have received a pre-addressed return envelope. If
you do not have this envelope, you can use any envelope as long as it is addressed to the RRB office
shown below. IVo matter which envelope you use, you must put the correct postage on the envelope.
Be careful to provide enough postage because your report may weigh more than a standard letter.
The U.S. Postal Service will not deliver your report unless it has the correct postage.
Address envelope to:
U S Railroad Retirement Board
Disability Benefits Division
844 N Rush Street
Chicago IL 60611-2092
If you do not want to use the mail, you can send a facsimile of the entire r e ~ o rto:
t
b Facsimile Number
(312) 751-7167
If you need information or assistance, contact:
b
Telephone Number:
-
Form G-254 (XX-XX)
Page 16
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-
-
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| File Type | application/pdf |
| File Modified | 2008-12-18 |
| File Created | 2008-12-18 |