G-212 (01-09) Public Service Pension Monitoring Questionnaire

Form Approved
OMB No. 3220-0136

UNITED STATES OF AMERICA

R.An-ROAD RETIREMENT BOARD
844 NORTH RUSH STREET
CHICAGO, IL 60611-2092
WWW.RRB.GOV
OFFICE HOURS: 9:00 AM TO 3:30 PM
MONDAY THROUGH FRIDAY

TOLL-FREE NUMBER:

1-877-772-5772

In reply refer to

We are required by law to reduce the tier 1 portion of your railroad retirement annuity because you
are currently receiving a public service pension. We need to verify the current amount of your
public service pension to ensure we are paying you correctly. Please complete Items 1 through 7
on the next page then sign and date the Certification Statement in Item 8.
Be sure to return the completed form, along with a copy of your latest public service pension
award or adjustment letter, within 15 days of the date of this letter.
If you have any questions about this letter or need additional information, contact our office located
at
. The telephone number is

Enclosure
Envelope

PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICES
The Railroad Retirement Board (RRB) is authorized to collect this information under section 7(b )(6) of the
Railroad Retirement Act. This information is needed to determine whether any public service pension that
you are currently receiving will affect your railroad retirement benefits. You are not required to provide the
information requested by this form. However, your failure to provide us with the requested information may
result in our being unable to pay you benefits. The information you provide may be disclosed for purposes of
verification to your former public service employer(s).
We estimate it takes an average of 15 minutes to complete this form, including the time to review the
instructions, get the needed data, and review 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 the completion time, to Chief of Information Resources
Management, Railroad Retirement Board, 844 North Rush Street, Chicago, IL 60611-2092.

G-212 (01-09)

Form Approved
OMB No. 3220-0136

United States of America
Railroad Retirement Board

1. Enter the name of the agency or organization that pays
your public service pension.
2.

Enter the current amount of your public service pension.
NOTE: This amount should be after reductionfor early

retirement or election ofa survivor benefits option, but before

deductions for health insurance, Medicare premium

reimbursement, bonds, tax withholding and other allotments.

$

/

3. Enter the effective date of this amount.

/

Mo.

Day

Year

Mo.

Day

Year

Mo.

Day

Year

4. Enter the date ofthe first payment you received for this

amount.

5. Enter the effective date ofthe next cost-of-living

increase you expect to receive. If you do not receive

cost-of-living increases, enter "None. H

DYes-(Go to Item 7)
D No-(Go to Item 8)

6. Was your cost-of-living increase paid in a lump sum?
7. Enter the amountofthe lump sum and the period it

covered.

$

From:
Day

Mo.

Year

/- -/- -

To:
Mo.

Day

Year

8. Certification Statement
I understand that civil and criminal penalties may be imposed on me for false or fraudulent
statements or for withholding information to cause payment of benefits by the RRB. I affirm
that, to the best of my knowledge, the information I have given is true, complete, and correct.
Signature

Date

Print Name

Daytime Telephone Number

(

)

­

***PLEASE ATTACH A COPY OF YOUR LATEST PSP AWARD or ADJUSTMENT LETTER***

G-212 (01-09)