Form RL-231-F (08-02) RL-231-F (08-02) Request to Non-Railroad Employer for Information About A

Form Approved
OMB NO.3220-0107

In reply refer to

The person named above is receiving an annuity under the Railroad Retirement Act (RRA), a
Federal law. Work activity and earnings may affect his (her) entitlement to that annuity.
Social Security records show that you reported wages for this person in the following year(s):
Please furnish the information requested on the next page. Section 7(b)(6) of the RRA authorized
the Railroad Retirement Board (RRB) to gather this information in order to determine if the
employment has any effect on the annuity. If you fail or refuse to furnish the requested
information, non-payment of the annuity to the person named above may result.
We estimate this form takes an average of thirty 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 aspects of this form, including suggestions for reducing the
completion time, to Chief of Information Resources Management, Railroad Retirement Board, 844
N. Rush St., Chicago, IL. 6061 1-2092.
Please return this form to the RRB in the enclosed envelope. If you need help in completing this
form, contact the nearest office of the RRB. Most RRB offices are open to the public from 9:00
A.M. to 3:30 P.M. Monday through Friday.
Sincerely,

Enclosure
Envelope

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

FORM APPROVED
OMB NO. 3220-0107

Please provide the information in the items checked below, and sign and date the form before
returning it.
1. Date began employment with you

. (If still workirrg, so state.)

2. Date last in your employ

January
February
March
Apr~l
May
June
July
August
September
October
November
December
Total
Remarks:

4. Other

I acknowledge that knowingly providing false, incomplete, or fraudulent information to the RRB is a
crime punishable by civil and criminal penalties. I certify that the information provided is true,
complete, and correct to the best of my knowledge.
of Employer or Authorized Official

Date

Business Phone