Download:
pdf |
pdfCURRENT
United States of America
Railroad Retirement Board
Form Approved
OMB No. 3220-0187
Continuing Disability Report
Paperwork Reduction Act and 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 such benefits. If you fail or refuse to furnish 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 governmental 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 Associate Chief Information Officer for Policy and Compliance, Railroad Retirement
Board, 844 North Rush Street, Chicago, Illinois 60611-1275.
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 earn over $880.00. You must notify the
nearest office of the RRB if your earnings exceed $880.00 a month.
Month
Day
Year
TO PRESENT
THE PERIOD COVERED IN THIS REPORT IS
Section 2
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.
1 Employee’s Name
2 Employee’s Social Security Number
3 Employee’s Railroad Retirement Claim Number
4 Your Name
5 Your Social Security Number
Work for
Employer
Information about Work for an Employer
6 Have you worked for an employer (railroad or nonrailroad)
during the period 99/99/9999 to present?
Yes
No
Section 3
Identifying
Information
Go to Item 7
Go to Section 4
Form G-254 (04-17) Destroy Prior Editions
Last Work
for
Employer
7 Enter information 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 information about your last employer first.)
a (1) First Employer’s Name
(2) Employer’s Address
(3) Employer’s Telephone Number (Include Area Code)
(
)
(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
$
(9) Hourly Rate of Pay
$
(8) Hours Worked Per Day
Day
Year
(10b) Date Work
Ended
Month
Day
Year
Month
(10a) Date Work
Began
(11) If work has ended, explain why.
Second
Last
Employer
b (1) Second Employer’s Name
(2) Employer’s Address
(3) Employer’s Telephone Number (Include Area Code)
(
)
(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.)
(7) Days Worked Per Week
(6) Monthly Rate of Pay
$
(9) Hourly Rate of Pay
$
(8) Hours Worked Per Day
Day
Year
(11) If work has ended, explain why.
Form G-254 (04-17)
(10b) Date Work
Ended
Month
(10a) Date Work
Began
Page 2
Month
Day
Year
Third
Last
Employer
7 c (1) Third Employer’s Name
(2) Employer’s Address
(3) Employer’s Telephone Number (Include Area Code)
(
)
(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.)
(7) Days Worked Per Week
(6) Monthly Rate of Pay
$
(9) Hourly Rate of Pay
(8) Hours Worked Per Day
$
Day
Year
(10b) Date Work
Ended
Month
Day
Year
Month
(10a) Date Work
Began
(11) If work has ended, explain why.
(If you need more space to list employers, continue in Section 6)
Earnings
8 List any months (in month/year format) and their corresponding years during the period 99/99/9999
9 a Have your earnings included any other payment,
such as tips, bonuses, child care, sick or vacation
pay, free meals, room or transportation?
Special
Earnings
Yes
No
to present, in which you earned more than $880.00.
Go to Item 9b
Go to Item 10
b List below type of other payment(s) received, estimated dollar value, frequency of payment,
11
Did you continue in or return to the same work
duties, hours, and pay as you had before your
disabling conditions began?
Special
Employment
12 a Are (were) you employed by a spouse, friend
or other relative or through a special training or
rehabilitation program?
Page 3
Yes
No
Continue
or Return
to Work
Yes
No
Yes
No
Did you work 3 months or less and then stop work
because of your disabling condition?
10
3 Months
or Less
Work
and employer’s name.
Go to Item 14
Go to Item 12
Go to Item 12b
Go to Item 13
Form G-254 (04-17)
Different
Job
Duties
13 a Have your job duties differed from those of other
workers with the same job title?
Yes
No
12 b Explain how and why you were hired.
Special
Employment
(Continued)
Go to Item 13b
Go to Item 14
b Check all that apply then go to Item 13c.
1. Shorter hours
4. Extra help given
7. Other - Explain in Item 13c
2. Different pay scales
5. Lower production
3. Fewer or easier duties
6. Lower quality
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 one employer, identify the
employer after each explanation.
that are necessary for you to work? (For example,
prescription medications, medical services, attendant care, medical devices, equipment, prosthesis,
or similar items or services.)
b List each impairment-related expense and provide a paid receipt.
Form G-254 (04-17)
Page 4
Yes
No
14 a Do you have any impairment–related expenses
Impairment–
Related
Expenses
Go to Item 14b
Go to Section 4
Section 4
Information about Self-Employment
Only complete Section 4 if you are or were self-employed during the period 99/99/9999 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 pay or not, and without regard to how the business is
organized (e.g., sole proprietorship, partnership, corporation, LLC, etc.). Otherwise, go to Section 5.
business.
c Check the box that describes the nature of the
Yes
No
Farm
Non-Farm
b Did you work 40 or more hours a month?
Sole Owner
Farm Tenant
Farm Landlord
15 a Enter the name and address of the business.
Yes - Go to Item 15f(2)
No - Go to Item 15g
d Enter the primary product or service.
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.
Partnership
Corporation
LLC
e Check the box that describes the business in terms
g Enter, below, the requested information about your monthly self-employment income for each month
during the period 99/99/9999 to present, starting with the latest month. If you need more space,
continue in Section 6 or attach a separate piece of paper.
Month
Year
Hours Worked
in Month
Gross Income
Net Income
work for any corporation at anytime (including a corporation owned by a
family member or friend) whether for pay or not, since 99/99/9999?
h Did you become a corporate officer, own or operate a corporation, or perform
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 99/99/9999 to present?
Page 5
Self–
Employment
Yes
No
Form G-254 (04-17)
Self–
Employment
(Continued)
15 k Describe the duties you perform on an average work day. Include any changes in your
Assistants
16 a Because of your disabling condition, do you need
Go to Item 16b
Go to Item 17
c Check the box that describes when you receive assistance.
b Enter the number of assistants you have.
additional help to perform your usual duties?
Yes
No
business because of your disabling condition, such as a reduced or restricted number of clients,
customers or business hours, lower volume, fewer acres under cultivation, etc.
By the day
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 (04-17)
Page 6
Yes
No
16 f Does your assistant(s) get paid?
Assistants
(Continued)
Go to Item 16g
Go to Item 16h
Yes
No
Yes
No
h Is your assistant(s) related to you?
g Enter the amount your assistant(s) gets paid. (Show if per hour, day, or month.)
Go to Item 16i
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 or
supervised other employees during the period
99/99/9999 to present?
Go to Item 17b
Go to Item 18
b Describe the type of management or supervisory decisions you made, how much time you
spent making them, and any changes that have taken place.
Page 7
Form G-254 (04-17)
additional special services been supplied?
Yes
No
20 Do you still receive this special assistance or have
Yes
No
Yes
No
or other source in setting up your business?
19 Did you receive any special assistance from an agency
condition began?
Yes
No
18 Did you start your business after your disabling
Business
Began
Go to Item 19
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.
Business
Expenses
22 Are there any normal business expenses paid for
or furnished by another person or organization (for
example, free space or utilities)?
Go to Item 23
Go to Section 5
23 List the business expenses paid for or furnished, and provide the dollar value.
24 Explain why and by whom these expenses were furnished.
that are necessary for you to work? (For example,
prescription medications, medical services,
attendant care, medical devices, equipment,
prosthesis, or similar items or services.)
26 b List each impairment-related expense and provide a paid receipt.
Form G-254 (04-17)
Page 8
Yes
No
25 a Do you have any impairment–related expenses
Impairment
Related–
Expenses
Go to Item 25b
Go to Section 5
Section 5
Condition
Before
Full
Retirement Age
Information about Your Condition before Full Retirement Age
26 a Describe your present medical condition.
b Describe any change (better or worse) in your condition, if any, during the period 99/99/9999 to
condition during the period 99/99/9999 to present?
d Have you received any treatment or care for your
Yes
No
Yes
No
working now?
c Does your condition prevent you from
present. If none, enter “None.”
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
or Care
27 a (1) Enter the name and address of the most recent source of treatment or care (doctor, hospital, or clinic).
(2) Enter the Patient Number (if applicable).
(3) Enter the telephone number of the treatment source (include area code).
(
)
(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 (04-17)
Treatment
or Care
(Continued)
27 b (1) Enter the name and address of the second most recent source of treatment or care (doctor, hospital, or clinic).
(2) Enter the Patient Number (if applicable).
(3) Enter the telephone number of the treatment source (include area code).
(
)
(4) Enter the date(s) you were treated.
(5) Describe the condition(s) for which you received treatment.
(6) Describe the treatment.
a Are you taking medication or receiving
Medication 28
treatment now?
Yes
No
(If you need more space to list sources of care, continue in Section 6)
Go to Item 28b
Go to Item 29
b Enter the medication or treatment below. Note: If you are taking prescription medication, furnish
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 (04-17)
Page 10
Yes
Enter doctor’s name then
go to Item 30
No
Go to Item 30
Yes
No
Go to Item 30b
Go to Item 29b
Go to Item 30
b Describe the restriction(s).
different from the name of the doctor(s) shown in Item
27a or Item 27b?
c Is the name of the doctor who restricted your activities
30 a Has your doctor told you that you are able
to return to work?
Doctor’s Name: _____________________________
Return
to Work
Yes
No
29 a Has your doctor restricted your activities?
Restriction
of
Activities
Month
b Enter the date your doctor said you could
Go to Item 31
Day
Year
Doctor’s Name: _____________________________
Activities
Yes
able to return to work different from the name of the
doctor(s) shown in Item 27a or Item 27b?
Enter doctor’s name then
go to Item 31
No
Go to Item 31
c Is the name of the doctor who told you that you are
return to work.
31 a 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
Explanation
No Hard
Walking
Eating
Bathing
Dressing, tying shoes,
combing hair, etc.
Other bodily needs
Indoor chores
(cooking, cleaning, etc.)
Outdoor chores
(shopping, yardwork,
etc.)
Driving a motor vehicle
Using public
transportation
Talking to and dealing
with other people
Page 11
Form G-254 (04-17)
Yes
No
Yes
No
31 b Do you use any assistive equipment or devices,
for example, cane, oxygen, wheelchair, etc.?
Activities
(Continued)
Go to Item 31c
Go to Item 32
c List the equipment or device(s).
Rehabilitation
Agency
32 a During the period 99/99/9999 to present, have you received
services, such as training, counseling, placement, medical
examination, treatment, etc., from other agencies, such as
VA, Worker’s Compensation, Welfare, etc...?
Go to Item 32b
Go to Item 33
b Enter the Name, Address, and Telephone Number of your vocational rehabilitation counselor/agency
(include area code).
(
)
c Enter the date(s) you received services.
33 a Have you attended school (trade, vocational,
or academic) during the period 99/99/9999 to
present?
Yes
No
Education
d Describe the services you received.
Go to Item 33b
Go to Section 7
b Enter the Name, Address, and Telephone Number of the school (include area code).
Form G-254 (04-17)
(
)
Page 12
Education
(Continued)
33 c Briefly describe the type of training you received.
d Enter the dates you attended the school.
Section 6
Continuation 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 (04-17)
Will this report be signed by a guardian or any
other person representing the beneficiary?
Yes
No
Authorization 35
and
Certification
Authorization and Certification
Section 7
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.
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.
Date
Month
Signature
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.
Day
Year
Daytime Telephone Number (Include Area Code)
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
Area Code
Telephone Number
Area Code
Telephone Number
Daytime Telephone Number
b. Signature of Witness
Address (Number and Street)
City, State, and ZIP Code
Form G-254 (04-17)
Daytime Telephone Number
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” 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 60611-1275
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:
Telephone Number:
Page 15
Form G-254 (04-17)
| File Type | application/pdf |
| File Title | G-254 1-16.indd |
| Author | KINGSLA |
| File Modified | 2017-04-12 |
| File Created | 2015-12-08 |