G-254A(proposed) Continuing Disabiltiy Update Report

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0187

Name and Address

CONTINUING DISABILITY
UPDATE REPORT
Daytime Telephone Number (Include Area Code)
Employee's Railroad Retirement Claim Number

Paperwork Reduction Act/Privacy Act Notices
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 your benefits. If you
fail or refuse to furnish information which is necessary to determine your continuing entitlement to benefits,
nonpayment 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 to comply with Federal law requiring the exchange of
information between the RRB and another agency.
We estimate this form takes an average of 5 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 Rush St, Chicago, Illinois 60611-2092.
REPORT PERIOD (Answer all questions for the following period):
FROM TO PRESENT
1.

During the report period, did work for a railroad?
DYES - Complete Items 1a-d, showing most recent work first.
WORK BEGAN

WORK ENDED

MonthlYear

MonthlYear

MONTHLY EARNINGS

a.

$

b.

$

c.

$

d.

$

o NO - Go to Item 2
JOB TITLE

G-254A (xx-xx)

-2­

2. During the report period did work for someone other than a railroad or self-employed?
DYES - Complete Items 2a-d, showing most recent work first.
WORK BEGAN

WORK ENDED

MonthlYear

MonthlYear

D NO - Go to Item 3

MONTHLY EARNINGS

a.

$

b.

$

c.

$

d.

$

JOB TITLE

3. During the report period the doctor ... (Check only one answer.)
D and I have not discussed whether can work.

told me cannot work.

D told me can work.

4.

Which word best describes health now as compared to the beginning date of the report
period?

(Check only one answer.)

D BETrER

DSAME

DWORSE

I understand that civil and criminal penalties may be imposed upon me for: (1) providing false or fraudulent statements;
(2) withholding information or misrepresenting a fact or facts material to determining a right to benefits under the RRA;
and/or (3) failing to promptly report work earnings to the Railroad Retirement Board. I affirm that to the best of my
knowledge, the information I have provided on this form is true, complete, and correct.

SIGNATURE

DATE

G-254A (xx-xx)