RI 92-22 March 2013 Markup

Form Approved:
OMB No. 3206-0194

2012 Annuity Supplement
Earnings Report

U.S. Office of Personnel Management
Retirement Surveys & Students Branch
1900 E Street, NW
Washington, DC 20415-3562
For Agency Use Only

Claim Number
I

Date

II

III

IV

Case Name

Complete and return this form if your allowable earnings were more than $14,640.00 or if your FERS
Annuity Supplement was reduced in a previous year.
The annuity supplement part of your FERS benefit is subject to an earnings test similar to the one applied to social
security benefits and uses the same exempt amount, as required by law in 5 U.S.C. Section 8421a. Your annuity
supplement will be reduced $1.00 for every $2.00 by which you exceed the exempt amount ($14,640 for 2012).
By law, this reduction is effective July 1, 2013. We apply the test only to earnings you received in 2012 after
retirement and after you reach the Minimum Retirement Age (MRA). The exempt amount for 2013 is $15,120.
Please answer the following questions and return this survey form before May 15, 2013, or as soon as you know
the exact amount of your allowable earnings.
1. Is your annuity supplement currently reduced because you reported excess earnings in a previous year? (Darken
only one oval.)
Yes (Please skip directly to question 4 and report your earnings for 2012.)
No (Please continue to question 2.)

2. Did you have any earnings in 2012 after retirement? (Darken only one oval.)
Yes (Please continue to question 3.)
No (Do not return this form. You may throw it away or keep it for your records.)

3. Refer to the chart below to find out what you should report based on your year of birth.
Year of Birth

What You Should Report

1948 - 1952

Report all 2012 earnings after retirement, if your earnings were more than $14,640.

1953 - 1964

Report all 2012 earnings after retirement and after you turned 56 years old, if your
earnings were more than $14,640.

4. What were your earnings in 2012 after retirement?

.
Dollars

Warning:

Cents

Your earnings for 2012 will be verified through a computer match with the Social Security Administration's earning
file. Any intentionally false statement or willful misrepresentation is punishable by fine, imprisonment, or both
(18 U.S.C. 1001).

Signature

Previous editions are not usable

Daytime telephone number

Email address

Date (mm/dd/yyyy)

RI 92-22
Revised March 2013

Instructions:
1.

Read the section below entitled: How To Determine Amount of Earnings You Should Report. If you have questions, please
telephone (202) 606-0249 Monday through Friday between 9:30 AM and 5:00 PM, Eastern Time. If you use TTY
equipment, call 1-855-887-4957.

2.
3.

Provide clear and legible information. Do not detach any portion of this form.
Fill in, sign, and mail this report in the envelope provided, or mail the report to: U.S. Office of Personnel Management,
Retirement Surveys and Students Branch, FERS Annuity Supplement Survey, 1900 E St., NW, Washington, DC
20415-3562 or fax your response to (202) 606-0022.

4.

Retain copies of evidence supporting your claimed earnings in the event you are required to furnish documentation of
earnings.

5.

DO NOT include your annuity payments from OPM. Include, as earnings, all income from wages and self-employment that
you actually received plus deferred income you actually earned during 2012.

How To Determine The Amount of Earnings You Should Report
Include as earnings:

Do not include as earnings:

- All wages from employment covered by social security.
- All cash pay for agricultural work, domestic work in a
private home, service not in the course of your employer's
trade or business.
- All pay, cash or non-cash, for work as a home worker for a
non-profit organization, no matter the amount. (The social
security $100.00 tax test does not apply.)
- All pay for work not covered by social security, if the work
is done in the United States, including pay for:
Family employment,
Work as a student, student nurse, intern, newspaper
and magazine vendor,
Work for States or foreign governments or
instrumentalities, and
Work covered by the Railroad Retirement Act.

- Pensions or annuities paid as retirement income, including
your FERS benefit or any benefits received as a survivor.
- Monies which you earned before entitlement for annuity
supplement and/or received for annual leave upon
retirement. This includes separation incentives.
- Unemployment compensation.
- Gifts, insurance proceeds, inheritances, scholarships,
alimony, capital gains, net business losses, prize winnings.

Regardless of what income is called or who receives it, if it
is actually wages for services you performed or net earnings
from self-employment you secured, it must be included in
applying the earnings test.

- Payments-in-kind for domestic service in the employer's
private home, for agricultural labor, for work not in the
course of the employer's trade or business, or the value of
meals and lodging.
- Rentals from real estate which cannot be counted in
earnings from self-employment because, for instance, you
were not a real estate dealer.
- Interest and dividends not resulting from trade or business.
- Pay for Veteran's training and for jury duty.
- Payments by an employer which are reimbursement
specifically for your travel expenses and which are so
identified by the employer at the time of payment and/or
reimbursement or allowance for moving expenses, if they
are not counted as wages for social security purposes.

For more information about the Annuity Supplement, refer to Information for FERS Annuitants, RI 90-8. Information begins
in Part B. If you would like a copy of this booklet, call the Retirement Information Office toll free at 1-888-767-6738; (TTY)
1-855-887-4957; or write: U.S. Office of Personnel Management, Post Office Box 45, Boyers, Pennsylvania 16017. This booklet
is also available on the OPM website at www.opm.gov/retire/pubs/pamphlets/list.asp. Remember your annuity supplement will
stop at the end of the month you reach age 62 or the month before you become entitled to social security benefits, whichever is
earlier.
Privacy Act Statement/Public Burden Statement
Information you furnish will be used to determine your eligibility to continue receiving the annuity supplement and the amount of the supplement. Information
may be shared and is subject to verification via paper, electronic media, or through use of computer matching programs, with national, state, local, or other benefit
paying agencies in order to determine and issue benefits under their programs, to obtain information necessary for continuation of benefits under this program, or
to report income for tax purposes. It may also be shared and verified, as noted above, with law enforcement agencies when they are investigating a violation or
potential violation of civil or criminal law. Solicitation of this information is authorized by the Federal Employees' Retirement Law (Chapter 84, title 5, U.S.
Code). Provision of this information is voluntary; however, failure to supply accurate information may result in suspension of your annuity benefit.
We estimate providing this information takes an average 15 minutes per response, including the time for reviewing instructions, getting the needed data, and
reviewing the requested information. Send comments regarding our estimate or any other aspect of this form, including suggestions for reducing completion time,
to the United States Office of Personnel Management, Retirement Services Publications Team, (3206-0194), Washington, DC 20415-3430. The OMB Number,
3206-0194, is currently valid. OPM may not collect this information, and you are not required to respond, unless the number is displayed.
Reverse of RI 92-22
Revised March 2013