Annual Earnings Questionnaire

In reply refer to
Date of Birth:
Work Deduction Amount: $
Annual Earninqs Questionnaire

Our records show that part of your annuity is being reduced because you are working for your last
pre-retirement, nonrailroad employer. 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 corr~pletethe parts of the questionnaire corresponding to the type of
employment you had in [Year]. Attach a copv of vour [Yearl Forms W-2 and a copv of vour
Schedule SE if vou were self-employed in [Yearl. Below are some guidelines and instructions that
will help you complete the questionnaire.

P 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.
P 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 [Year] even if you do not provide a monthly breakdown of your earnings.
P Remember to provide an estimate of your earnings for calendar year [XXXX]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

Form G-19L (12-07)

United States o f America
Railroad Retirement Board

Form Approved
OMB NO.3220-0179

[Name]
PART A
COMPLETE THlS PART FOR EARNINGS

PART B

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

COMPLETE THlS PART FOR NET
SELF-EMPLOYMENT EARNINGS

PRE-RETIREMENT (NONRAILROAD)
FMPl OYER

1

Year] LAST PRE-RETIREMENT
EMPLAYER

IYearl NET SELF-EMPLOYMENT
TYPE OF WORK

IYearl OTHER POST RETIREMENT
EMPLOYER

ADDRESS

ADDRESS

ADDRESS

FEBRUARY

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MARCH

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MONTH
JANUARY

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EARNINGS IN MONTH

I MONTH
I JANUARY
I FEBRUARY

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MARCH

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(

I MONTH
1 JANUARY
I FEBRUARY

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EARNINGS IN MONTH

APRIL

APRIL

MARCH

MAY

MAY

JUNE

JUNE

JUNE

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I

I AUGUST
I SEPTEMBER
I OCTOBER

I JULY
I AUGUST
I SEPTEMBER
IOCTOBER

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I JULY
I AUGUST
I SEPTEMBER
I OCTOBER

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NOVEMBER

NOVEMBER

DECEMBER

DECEMBER

DECEMBER

1. TOTAL [YEAR]:
2. [YEAR] EARNINGS ESTIMATE FOR
THIS EMPLOYMENT: $XXX.XX
3. IF NO LONGER EMPLOYED, SHOW THE
DATE YOUR WORK ENDED:

4. TOTAL [YEAR]
5. [YEAR] EARNINGS ESTIMATE FOR
NET SELF-EMPLOYMENT: $XXX.XX
6. IF NO LONGER EMPLOYED, SHOW THE
DATE YOUR WORK ENDED:

7. TOTAL [YEAR]
8. [YEAR] EARNINGS ESTIMATE FOR
THIS EMPLOYMENT: $XXX.XX
9. IF NO LONGER EMPLOYED, SHOW THE

DATE

DATE YOUR WORK ENDED:
DATE

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Do your best to complete all items that pertain to our earnings, especially Items 1 through 9. Be sure to enclose copies of your

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Forms W-2 for [Year] and a copy of Schedule E if you were self-employed.
To avoid penalties, you must retum this questionnaire within 30 da s of the date of the form. If you need more time, let us know as
soon as possible. We can allow additional time if you have specia circumstances.

Y

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.

DA TE

SIGNA TURE

Daytime Telephone Number (optional)
(In case we have questions about your responses.)

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NOVEMBER

DATE

1
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APRIL

MAY
JLlLY

EARNINGS IN MONTH

Area Code

CZF

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

Tele3hone Number

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