RL-8A (Proposed) Occupational Disability Certification

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0187

PROPOSED
Beneficiary Name

OCCUPATIONAL DISABILITY
CERTIFICATION

Beneficiary Claim Number
Release Date

Paperwork Reduction Act and Privacy Act Notices
It is your responsibility as a disability annuitant to report to us any improvement in your impairment(s), work,
earnings, and/or certain other events that may affect your right to receive disability benefits. If you do not
return the signed certification to us within 30 days from the date of this notice, we will automatically conduct
a Continuing Disability Review. In some cases, failure to report may constitute a criminal violation under title
45 Section 231(l) or under other criminal or civil statutes.
We estimate this form takes an average of 15 minutes per response to complete, including the time needed
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 the completion time, to: Associate Chief
Information Officer for Policy and Compliance, Railroad Retirement Board, 844 N. Rush Street, Chicago, IL
60611-1275.
Completion Instructions


1

Enter your response to each question below for the period to .
Sign, date, and return this form, within 30 days of the Release Date noted above. Use the
enclosed, self-addressed envelope.
(a) Has your condition and/or impairment improved enough that you
are able to return to your railroad job?

Yes – Explain in Item 1(b)
No

(b)

2

(a) Have you performed any work for a railroad during the period
to ?

Yes – Explain in Item 2(b)
No

(b)

RL-8A (xx-xx)

3

Yes – Explain in Item 3(b)

(a) Have you performed any work for a non-railroad during the
period to ?

No
(b)

4

Yes – Explain in Item 4(b)

(a) Have you been self-employed, including as a partner, owner, or
co-owner, during the period to ?

No

(b)

5

Yes – Explain in Item 5(b)

(a) Have you served as a director or officer of a corporation, or as a
member of an LLC; did you own a company operated by a family
member; or did you operate a company owned by a family
member during the period to ?

No

(b)

Certification Statement
By signing this certification, I confirm that the above is true to the best of my knowledge. I understand that civil and
criminal penalties may be imposed on me for: (1) Providing false or fraudulent statements; (2) withholding information
or misrepresenting a fact or facts material to determine a right to benefits under the Railroad Retirement Act; and/or (3)
failing to promptly report work earnings to the Railroad Retirement Board.

SIGNATURE

DATE

RL-8A (xx-xx)