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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 fumish 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 govemmental 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 eam over $790.00. Please notify the
nearest office of the RRB if your eamings 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
Informatior
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
to present?
DYes" Go to Item 7
o
No
.. Go to Section 4
Form G-254 (XX-XX) Destroy Prior Editions
Last
Work
for
Employer
7 Enter infonnation 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 infonnation about your last employer first.)
a
(1)
First Employer's Name
(2)
Employer's Address
(3)
Employer's Telephone Number (Include Area Code)
)
"0'(
(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)
Hourly Rate of Pay
$
(10a) Date Work
Began
...
(11)
Second
Month
Day
Year
I
I
I I I
..
(10b) Date Work
Ended
Month
Day
I
I
Year
I
I I
If work has ended, explain why.
b (1) Second Employer's Name
Last
Employer
(2)
Employer's Address
(3)
Employer's Telephone Number (Include Area Code)
)
"0'(
(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)
Hourly Rate of Pay
$
.
(10a) Date Work
Began
Month
Day
I
I
Year
I
I
(11) If work has ended, explain why.
Fonn G-254 (XX-XX)
Page 2
.
(10b) Date Work
Ended
Month
Day
Year
I
I
I I I
Third
7 C (1) Third Employer's Name
Last
Employer
(2)
Employer's Address
(3)
Employer's Telephone Number (Include Area Code)
)
'D'(
(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) Hourly Rate of Pay
$
..
(10a) Date Work
Began
Month
Day
Year
I
I
I I I
..
(10b) Date Work
Ended
Month
Day
Year
I
I
I I I
(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
Special
9 a Have your eamings included any other payment,
Earnings
to present, in which you eamed more than $790.00.
such as tips, bonuses, child care, sick or vacation
pay, free meals, room or transportation?
...
0
0
.
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.
...
0
0
Yes
No
Did you continue in or retum to the same work
duties, hours, and pay as you had before your
disabling conditions began?
...
0
0
Yes .. Go to Item 14
No
Go to Item 12
a
...
0
0
3 Months
or Less
Work
10 Did you work 3 months or less and then stop work
Continue
11
or
because of your disabling condition?
Retur~
to Work
Special
Employ"
ment
12
Are (were) you employed by a friend or relative
or through a special training or rehabilitation
program?
Page 3
..
.
Yes .. Go to Item 12b
No
Go to Item 13
Form G-254 (XX-XX)
Special
Employ
ment
(Cont.)
12 b Explain how and why you were hired.
Different
.Iob
13 a Have your job duties differed from those of other
workers with the same job title?
Duties
0
0
Yes III- Go to Item 13b
No
III- Go to Item 14
b Check all that apply them go to Item 13c.
o
o
o
1. Shorter hours
4. Extra help given
o
o
2. Different pay scales
0
3. Fewer or easier duties
5. Lower production
0
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.
Impair
mentRelated
Expenses
14 a Do you have any impairment-related expenses
that are necessary for you to work? (For example,
prescription medications, medical services, atten
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
o
o
Yes III- Go to Item 14b
No
III- Go to Section 4
Section 4
Information about Self-Employment
Only complete Section 4 if you were self-employed during the period
to present. This would include self-employment
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 payor not, and without regard to how the business is organized (e.g., sole
proprietorship, partnership, corporation, LLC, etc.). Otherwise, go to Section 5.
Self
Employ
15 a
Enter the name and address of your business.
ment
0
Yes
No
....
0
0
0
....
0
0
0
b Did you work 40 or more hours a month?
....
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?
(2) Describe what you have received of value in lieu of
a salary or wages.
....
0
0
Sole Owner
Farm Tenant
Partnership
Corporation
o LLC
Farm Landlord
o Yes - Go to Item 15f(2}
o
No - Go to Item 15g
....
9 Enter, below, the requested information about your monthly self-employment income for each month
to present, starting with the latest month. If you need more space, continue in
during the period
Section 6 or attach a separate piece of paper.
Month
Year
Hours Worked
in Month
Net Income
Gross 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 payor not, since
?
....
0
0
Yes
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
to present?
Page 5
....
0
0
Yes
No
Form G-254 (XX-XX)
Self
Employ-
moot
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?
Dyes .... Go to Item 16b
o
No
.... Go to Item 17
o
By the day
b Enter the number of assistants you have.
C Check the box that describes when you receive assistance.
o
o
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 (XX-XX)
Page 6
Assistants
...
16 f Does your assistant(s) get paid?
(Cont.)
0
Yes III- Go to Item 16g
0
No
III- Go to Item 16h
9 Enter the amount your assistant(s) gets paid. (Show if per hour, day, or month.)
...
h Is your assistant(s) related to you?
0
Yes III- Go to Item 16i
0
No
III- Go to Item 16j
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
to present?
...
0
Yes III- Go to Item 17b
0
No
III- Go to Item 18
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)
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?
~
~
0
0
Yes
0
0
0
0
Yes
No
No
Yes
No
...
...
...
...
...
...
Go to ltem19
Go to Section 5
Go to Item 20
Go to Item 22
Go to Item 21
Go to Item 22
21 Describe the continued assistance or special services.
Busines
Expenses
22 Are there any normal business expenses paid for or
fumished by another person or organization (for
example, free space or utilities)?
o
o
Yes ... Go to Item 23
No
... Go to Section 5
23 List the business expenses paid for or fumished, and provide the dollar value.
24
Impair
ment
Related
Expenses
Explain why and by whom these expenses were fumished.
25 a
Do you have any impairment-related expenses
that are necessary for you to work? (For example,
prescription medications, medical services, atten
dant care, medical devices, equipment, prosthesis,
or similar items or services.)
b List each impairment-related expense and provide a paid receipt.
Form G-254 (XX-XX)
Page 8
o
o
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 Retire
mentAge
b Describe any change (better or worse) in your condition, if any, during the period
to present.
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
to present?
~
0
0
0
0
Yes
No
Yes
No
...
...
...
...
Go to Item 26d
Go to Item 26e
Go to Item 27
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).
'U' (
)
(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 (XX-XX)
Treatment
27 b (1) Enter the name and address ofthe second most recent source of treatment or care (doctor, hospital, or clinic).
or Care
(Cont.)
(2) Enter the Patient Number (if applicable).
(3) Enter the telephone number of the treatment source (include area code).
U (
)
(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
o
o
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, fumish
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
~
29 a Has your doctor restricted your activities?
of
Activities
Yes
0
Yes
0
No
0
0
Yes
different from the name of the doctor(s) shown in Item
27a or Item 27b?
~
Doctor's Name:
30 a Has your doctor told you that you are able
~
to return to work?
to Work
b Enter the date your doctor said you could
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
....
....
No
Go to Item 29b
Go to Item 30
b Describe the restriction(s).
c Is the name of the doctor who restricted your activities
Return
0
0
~
..
..
.....
No
Enter doctor's name then
go to Item 30
Go to Item 30
Go to Item 30b
Go to Item 31
I
Month
I
I
I
I
0
Yes
0
No
..
....
Day
I
Year
I
I I I I I I
Enter doctor's name then
go to Item 31
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
Walking
0
0
0
Eating
0
'0
0
Bathing
0
0
0
Dressing, tying shoes.
combing hair, etc.
0
0
0
Other bodily needs
0
0
0
Indoor chores
(cooking, cleaning, etc.)
U
U
U
Outdoor chores
(shopping. yardwork. etc.)
U
0
0
Driving a motor vehicle
0
0
0
Using public
transportation
0
U
0
Talking to and dealing
with other people
0
,
0
0
Explanation
Page 11
Form
G~254 (XX~XX)
Rehabilita
tion
Agency
32 a During the period
to present, have you received
services, such as training, counseling, placement,
medical examination, treatment, etc., from or through a
state vocational rehabilitation agency or other agencies,
such as VA, Worker's Compensation, Welfare, etc ... ?
o Yes
o No
.. Go to Item 32b
.. Go to Item 33
b Enter the Name, Address, and Telephone Number of your vocational rehabilitation counselor/agency.
'U' (
)
c Enter the date(s) you received services.
d Describe the services you received.
Education
33 a Have you attended school (trade, vocational, or
academic) during the period
present?
to
o
b Enter the Name, Address, and Telephone Number of the school.
'U' (
)
c Briefly describe the type of training you received.
d Enter the dates you attended the school.
Form G-254 (XX-XX)
DYes .. Go to Item 33b
Page 12
No
.. Go to Section 7
Section 6
Continua
lion and
Remarks
Continuation and Remarks
34 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.
(If you need more space, attach a separate sheet of paper)
Page 13
Form G-254 (XX-XX)
Section 7
Authorization
and
Certification
35
Authorization and Certification
Will this report be signed by a guardian or any
other person representing the beneficiary?
(
36
0
0
~
Yes
No
P.
P.
Read Note then go to Item 36
Go to Item 36
Note: If answered "Yes, " your guardian or representative must sign this report in Item 36.
)
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
~
Date
~
I
I
~~Y~.r
Month
I
I
Daytime Telephone Number (Include Area Code)
fi' (
37
)
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
Daytime Telephone Number
I Area Code
~
Telephone Number
I I
I I LI I
Area Code
Telephone Number
I I
I I I I I I
b. Signature of Witness
Address (Number and Street)
City, State, and ZIP Code
Daytime Telephone Number
Form G-254 (XX-XX)
~
Page 14
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:
..
"B'
Telephone Number:
Page 15
Form G-254 (XX-XX)
| File Type | application/pdf |
| File Modified | 2011-11-23 |
| File Created | 2011-11-23 |