RI30-002_2016_01_Form

Form Approved:
OMB No. 3206-0034

Annuitant's Report of Earned Income for 2015
32427

United States Office of Personnel Management
Retirement Programs, 4685 Log Cabin Drive, Macon, GA 31204-6307

If the address shown below is not correct, please
show any change next to your address below.

For Agency Use Only
Claim Number

I

II

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IV

Please read the instructions on the reverse side of this form
before completing. The instructions state what to include as
income and give examples of what not to include as income.
1. If you had any Earned Income for 2015, please fill in the boxes below and return this form.
Total the highest amounts (shown as "Social Security" or "Medicare Wages") shown on all of your W-2's and
enter below. Also, include self-employment as shown on your Schedule SE, and deferred income if applicable.
Fill in all 6 boxes using as many beginning zeros as you need. See the example.
Example: If you had earned income, write the full amount in the boxes and blacken the appropriate circle for that
amount. For earnings of $9,562.45, you would complete the boxes as shown below.
Example - $9562.45
Dollars

0

0

9

Cents

5

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.4

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Use a number 2 Pencil or a Black or Blue PEN to darken
the corresponding circle below each number.
Dollars
Cents

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2. Are you currently reemployed in the Federal service?
(See #4 on the reverse side of this form.)
No.
Yes, please complete 2a - 2d.

2b. Appointment type

2a. Dates of reemployment in the Federal service.
From: (MM/DD/YYYY)
To: (MM/DD/YYYY)

2d. Federal agency name and address if #2 is yes.

/

/

/

2c. Grade and step

/

Warning: Your earnings for 2015 will be verified through a computer match with the Social Security Administration's

Earnings file. Any intentionally false statement, willful concealment of material fact, or use of a writing or
document knowing the same to contain a false, fictitious, or fraudulent statement or entry, is a violation of the
law punishable by a fine of not more than $10,000 or imprisonment of not more than 5 years or both.
If signature is by mark "X", a witness must also
3. By my signature here, I certify that all information given
sign, date, and enter his or her address below.
by me on this form is true and correct to the best of my
Date
Witness' signature
knowledge and belief.
4. Date

5. Please provide your daytime phone
number, including the area code.

Previous editions are not usable.

Witness' address

RI 30-2
Revised January 2016

Instructions
The Office of Personnel Management (OPM) requires you as a Federal retiree who was under age 60 during the survey
year and receiving disability benefits to provide information if you had income from wages or self-employment during
2014. By law, you may earn money from working while also receiving disability benefits, providing your income from
wages and self-employment is less than 80% of the current rate of pay for the position from which you retired.
If your earned income during 2015 met or exceeded the 80% limitation, you are considered to be "restored to earning
capacity" and we will discontinue your disability benefits effective June 30, 2016. If this should happen, we will
notify you in writing before your final disability payment is sent. We will also notify you at that time if you are eligible for
an immediate non-disability retirement or a deferred retirement.
Do You Need to Complete and Return This Form within 30 Days?
Yes if in 2015, you:
1. Worked and earned money after retiring from Federal Service,
or
2. Were reemployed by the Federal government and are still employed.
If neither of these events occurred, you do NOT need to complete or return this form.
What Does The Term "Earned Income" Mean?
1. Any salary or pay you received working for someone else (including overtime, vacation pay, bonuses, and
severance pay, etc.)
2. If you are self-employed, any net profit you made from working or managing your own business.
3. Deferred income (income you earned but didn't receive during this calendar year).
4. If you are reemployed in Federal service, the gross income before your employing agency offsets your salary.
Generally, all income subject to Federal employment taxes or self-employment is considered earned income. It is
on any W-2 statement issued by your employer. DO NOT INCLUDE MONEY EARNED BEFORE YOU RETIRED.
Not Considered Earned Income
Income reported on form 1099, such as Civil Service Retirement benefits, annuities, pensions, Social Security benefits,
Veteran's benefits, and military retired pay, withdrawals from 401K plans, unemployment compensation, workers'
compensation, interest and dividends from savings accounts, stocks, personal loans, or home mortgages held,
insurance proceeds, gifts, inheritances, estates, trusts, endowments, prizes, awards, gambling or lottery winnings,
alimony/child support, scholarships or fellowships, pay for jury duty, capital gains from the sale of personal property,
amounts received in court actions, and rents or royalties UNLESS received in the course of your trade or business.
Need Help?
If you need another form or have additional questions about what is considered earned income or about completing
and returning this form, you can call us weekdays at (202) 606-0249. For those individuals living outside the
Washington DC metro area, you can call our Retirement Information Office toll free at 1-888-767-6738 from 7:30 AM
to 5:30 PM, Eastern Time. If you prefer, you can write us at:
Office of Personnel Management
Retirement Surveys and Student Branch
Washington, DC 20415-3562
Privacy Act and Public Burden Statements
Privacy Act: Solicitation of this information is authorized by the Civil Service
Retirement Law (Chapter 83, title 5, U.S. Code) and the Federal Employees
Retirement Law (Chapter 84, title 5, U.S. Code). The information you furnish will
be used to identify records properly associated with your application for Federal
benefits, to obtain additional information if necessary, to determine and allow
present or future benefits, and to maintain a uniquely identifiable claim file. The
information may be shared and is subject to verification via paper, electronic
media, or through the use of computer matching programs, with national, state,
local or other charitable or social security administrative agencies in order to
determine benefits under their programs, 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.
Public Burden Statement: We estimate this form takes an average of 35 minutes per
response to complete, including the time for reviewing instructions, getting needed
data, and reviewing the completed form. Send comments regarding our estimate or
any other aspect of this form, including suggestions for reducing completion time, to
the Office of Personnel Management, Retirement Services Publications Team
(3206-0034), Washington, D.C. 20415-3430. The OMB Number 3206-0034 is
currently valid. OPM may not collect this information and you are not required to
respond unless this number is displayed.