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pdfUnited States of America
Railroad Retirement Board
Form Approved
OMB No. 3220-0187
Continuing Disability Report
Paperwork Reduction Act/Privacy 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 Information Resources Management, Railroad Retirement Board, 844 North Rush
Street, Chicago, Illinois 60611-2092.
Section 1
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 Items 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 $790.00. Please notify the
nearest office of the RRB if your earnings exceed $790.00 a month.
Month
Day
Year
THE PERIOD COVERED IN THIS REPORT IS
Section 2
TO PRESENT
Identifying Information
Check the information provided for Items 1 through 5 for accuracy.
If the information is correct, go to Section 3.
If the information is not correct, cross out the incorrect information and enter the correct information above it.
If the information is missing, fill it in.
Identifying
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
Section 3
Work for
Employer
Information about Work for an Employer
6 Have you worked for an employer (railroad or
nonrailroad) during the period shown in Section 1,
above?
Yes
Go to Item 7
No
Go to Section 4
Form G-254 (12-11) Destroy Prior Editions
Last
Work
for
Employer
7 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
(2)
Employer's Address
(3)
Employer's Telephone Number (Include Area Code)
(
)
(4)
Title/Name of your job
(5)
Describe your job duties. (Include weights lifted and how frequently lifted; hours spent standing/sitting;
frequency of bending/stooping/climbing, etc.)
(6)
Monthly Rate of Pay
$ __________________
(7) Days Worked Per Week
(8)
Hours Worked Per Day
(9)
(10a) Date Work
Began
Month
Day
Year
Hourly Rate of Pay
$
(10b) Date Work
Ended
Month
Day
Year
(11) If work has ended, explain why.
Second
Last
b (1) Second Employer's Name
Employer
(2)
Employer's Address
(3)
Employer's Telephone Number (Include Area Code)
(
)
(4)
Title/Name of your job
(5)
Describe your job duties. (Include weights lifted and how frequently lifted; hours spent standing/sitting;
frequency of bending/stooping/climbing, etc.)
(6)
Monthly Rate of Pay
$ __________________
(7) Days Worked Per Week
(8)
Hours Worked Per Day
(9)
(10a) Date Work
Began
Month
Day
Year
(11) If work has ended, explain why.
Form G-254 (12-11)
Page 2
Hourly Rate of Pay
$
(10b) Date Work
Ended
Month
Day
Year
Third
7 c (1) Third Employer's Name
Last
Employer
(2)
Employer's Address
(3)
Employer's Telephone Number (Include Area Code)
(
(4)
)
Title/Name of your job
(5) Describe your job duties. (Include weights lifted and how frequently lifted; hours spent standing/sitting;
frequency of bending/stooping/climbing, etc.)
(6)
(7) Days Worked Per Week
Monthly Rate of Pay
$__________________
(8) Hours Worked Per Day
(9) Hourly Rate of Pay
$
(10a) Date Work
Began
Month
Day
Year
Month
(10b) Date Work
Ended
Day
Year
(11) If work has ended, explain why.
(If you need more space to list employers, continue in Section 6)
Earnings
8 List any months during the period shown in Section 1, in which you earned more than $790.00.
Special
9 a Have your earnings included any other payment,
Earnings
such as tips, bonuses, child care, sick or vacation
pay, free meals, room or transportation?
Yes
Go to Item 9b
No
Go to Item 10
b List below type of other payment(s) received, estimated dollar value, frequency of payment,
and employer’s name.
3 Months
or Less
Work
10 Did you work 3 months or less and then stop work
because of your disabling condition?
Continue 11
or Return
to Work
Special
Employment
Did you continue in or return to the same work
duties, hours, and pay as you had before your
disabling conditions began?
12 a Are (were) you employed by a friend or relative
or through a special training or rehabilitation
program?
Page 3
Yes
No
Yes
Go to Item 14
No
Go to Item 12
Yes
Go to Item 12b
No
Go to Item 13
Form G-254 (12-11)
Special
12 b Explain how and why you were hired.
Employment
(Cont.)
Different
Job
13 a Have your job duties differed from those of other
workers with the same job title?
Duties
Yes
Go to Item 13b
No
Go to Item 14
b Check all that apply them go to Item 13c.
1. Shorter hours
2. Different pay scales
3. Fewer or easier duties
4. Extra help given
5. Lower production
6. Lower quality
7. Other - Explain in Item 13c
c Explain in more detail, each selection made in Item 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
employer after each explanation.
Impairment–
Related
Expenses
14 a Do you have any impairment–related expenses
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 (12-11)
Page 4
Yes
Go to Item 14b
No
Go to Section 4
Section 4
Information about Self-Employment
Only complete Section 4 if you were self-employed during 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.
Self
15 a Enter the name and address of your business.
Employment
Yes
b Did you work 40 or more hours a month?
No
c Check the box that describes the nature of the
business.
Farm
Non-Farm
d Enter the primary product or service.
e Check the box that describes the business in terms
of arrangement and/or ownership.
f (1) Have you received anything of value in lieu of salary
or wages for any work that you performed?
Sole Owner
Partnership
Farm Tenant
Corporation
Farm Landlord
LLC
Yes - Go to Item 15f(2)
No - Go to Item 15g
(2) Describe what you have received of value in lieu of
a salary or wages.
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
Year
Hours Worked
in Month
Gross Income
Net Income
h Did you become a corporate officer, own or operate a corporation, or perform
Yes
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 1?
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 1?
Yes
No
Page 5
Form G-254 (12-11)
Self
Employment
15 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.
(Cont.)
Assistants
16 a Because of your disabling condition, do you need
additional help to perform your usual duties?
Yes
Go to Item 16b
No
Go to Item 17
b Enter the number of assistants you have.
By the day
c Check the box that describes when you receive assistance.
By the week
By the month
d Enter how many hours your assistant(s) spends helping you? (Show if per day, week, or month.)
e Describe what your assistant(s) does to help you.
Form G-254 (12-11)
Page 6
Assistants
16 f Does your assistant(s) get paid?
(Continued)
Yes
Go to Item 16g
No
Go to Item 16h
g Enter the amount your assistant(s) gets paid. (Show if per hour, day, or month.)
h Is your assistant(s) related to you?
Yes
Go to Item 16i
No
Go to Item 16j
Yes
Go to Item 17b
No
Go to Item 18
i Enter the relationship of your assistant(s) to you.
j Explain why you need additional help.
Decisions
17 a Have you made management decisions during
the period shown in Section 1?
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 (12-11)
Busines
Began
18 Did you start your business after your disabling
condition began?
19 Did you receive any special assistance from an
agency or other source in setting up your business?
20 Do you still receive this special assistance or have
additional special services been supplied?
Yes
Go to Item19
No
Go to Section 5
Yes
Go to Item 20
No
Go to Item 22
Yes
Go to Item 21
No
Go to Item 22
Yes
Go to Item 23
No
Go to Section 5
21 Describe the continued assistance or special services.
Busines
Expenses
22 Are there any normal business expenses paid for or
furnished by another person or organization (for
example, free space or utilities)?
23 List the business expenses paid for or furnished, and provide the dollar value.
24 Explain why and by whom these expenses were furnished.
Impairment
Related
Expenses
25 a Do you have any impairment–related expenses
that are necessary for you to work? (For example,
prescription medications, medical services, attendant care, medical devices, equipment, prosthesis,
or similar items or services.)
26 b List each impairment-related expense and provide a paid receipt.
Form G-254 (12-11)
Page 8
Yes
Go to Item 25b
No
Go to Section 5
Section 5
Condition
Information about Your Condition before Full Retirement Age
26 a Describe your present medical condition.
Before
Full Retirement Age
b Describe any change (better or worse) in your condition, if any, during the period show in Section 1.
If none, enter “None.”
c Does your condition prevent you from
working now?
d Have you received any treatment or care for your
condition during the period show in Section 1?
Yes
Go to Item 26d
No
Go to Item 26e
Yes
Go to Item 27
No
Go to Item 28
e Explain why your condition does not prevent you from working now.
Treatment
27 a (1) Enter the name and address of the most recent source of treatment or care (doctor, hospital, or clinic).
or Care
(2) Enter the Patient Number (if applicable).
(3) Enter the telephone number of the treatment source (include area code).
(
)
(4) Enter the date(s) you were treated.
(5) Describe the condition(s) for which you received treatment.
(6) Describe the treatment.
Page 9
Form G-254 (12-11)
Treatment
27 b (1)
Enter the name and address of the second most recent source of treatment or care (doctor, hospital, or clinic).
or Care
(Continued)
(2) Enter the Patient Number (if applicable).
(3) Enter the telephone number of the treatment source (include area code).
(
)
(4) Enter the date(s) you were treated.
(5) Describe the condition(s) for which you received treatment.
(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
treatment now?
Yes
Go to Item 28b
No
Go to Item 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 (12-11)
Page 10
Restriction
Yes
Go to Item 29b
No
Go to Item 30
different from the name of the doctor(s) shown in Item
27a or Item 27b?
Yes
Enter doctor’s name then
go to Item 30
Doctor’s Name: _____________________________
No
Go to Item 30
Yes
Go to Item 30b
No
Go to Item 31
29 a Has your doctor restricted your activities?
of
Activities
b Describe the restriction(s).
c Is the name of the doctor who restricted your activities
Return
30 a Has your doctor told you that you are able
to Work
to return to work?
Month
b Enter the date your doctor said you could
Day
Year
return to work.
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 Item 27a or Item 27b?
Doctor’s Name: _____________________________
Activities
Yes
Enter doctor’s name then
go to Item 31
No
Go to Item 31
31 Check the one box after each activity listed below that best describes your ability to do that activity.
“Yes” —
“No” —
“Hard” —
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.
Activity
Yes
No Hard
Explanation
Walking
Eating
Bathing
Dressing, tying shoes,
combing hair, etc.
Other bodily needs
Indoor chores
(cooking, cleaning, etc.)
Outdoor chores
(shopping, yardwork, etc.)
Driving a motor vehicle
Using public
transportation
Talking to and dealing
with other people
Page 11
Form G-254 (12-11)
Rehabilitation
Agency
32 a During the period shown in Section 1, have you
received services, such as training, counseling, placement, medical examination, treatment, etc., from or
through a state vocational rehabilitation agency?
Yes
Go to Item 32b
No
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.
Other
Agencies
33 a During the period shown in Section 1, have you
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 school.
(
)
c Briefly describe the type of training you received.
d Enter the dates you attended the school.
Form G-254 (12-11)
Page 12
Yes
Go to Item 33b
No
Go to Item 34
Other
33 a Describe the services you received.
Agencies
(Continued)
Education
34 a Have you attended school (trade, vocational, or
academic) during the period shown in Section 1?
Yes
Go to Item 34b
No
Go to Section 7
b Enter the Name, Address, and Telephone Number of the school.
(
)
c Briefly describe the type of training you received.
d Enter the dates you attended the school.
Section 6
Continuation and
Remarks
Continuation and Remarks
35 This section is to be used for the continuation of answers to other items. Be sure to include the
item number at the beginning of the answer you wish to continue. You may also use this section
to enter additional information that you feel may be important to include.
(Continue on next page)
Page 13
Form G-254 (12-11)
Continua-
35
tion and
Remarks
(Continued)
(If you need more space, attach a separate sheet of paper)
Form G-254 (12-11)
Page 14
Section 7
Authorization 36
and
Authorization and Certification
Will this report be signed by a guardian or any
other person representing the beneficiary?
Yes
Read Note then go to Item 37
No
Go to Item 37
Certification
Note: If answered “Yes,” your guardian or representative must sign this report in Item 37.
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 affirm 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-1d, Employee Disability Benefits, and RB-9,
Employee and Spouse Events That Must Be Reported. 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
Month
Day
Year
Date
Daytime Telephone Number (Include Area Code)
(
38
)
If this certification is signed by mark (“X”) in Item 36, 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
Area Code
Telephone Number
Area Code
Telephone Number
Daytime Telephone Number
b. Signature of Witness
Address (Number and Street)
City, State, and ZIP Code
Daytime Telephone Number
Page 15
Form G-254 (12-11)
Section 8
How to Return Your Report
Before you return your report, check to make sure that:
Every question that applies to you has been answered.
You have entered “Unknown” to 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. No 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 report to:
Facsimile Number
(312) 751-7167
If you need information or assistance, contact:
Telephone Number:
Form G-254 (12-11)
Page 16
| File Type | application/pdf |
| File Title | OtherG-254.pff |
| Author | mcneasm |
| File Modified | 2011-12-06 |
| File Created | 2011-12-06 |