Form G-252 (04-17) G-252 (04-17) Self-Employment/Corporate Officer Work and Earnings Moni

Self-Employment/Corporate Officer Work and Earnings Monitoring

Form G-252 (04-17)

Self-Employment/Corporate Officer Work and Earnings Monitoring

OMB: 3220-0202

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United States of America
Railroad Retirement Board

CURRENT

Form Approved
OMB No. 3220-0202

SELF-EMPLOYMENT/CORPORATE OFFICER
WORK AND EARNINGS MONITORING
Paperwork Reduction Act and Privacy Act Notices
The Railroad Retirement Board (RRB) is authorized to collect the information on this form under Section 7(b)(6) of the
Railroad Retirement Act (RRA). The information is needed to determine if your work/earnings affect your eligibility to
continue receiving railroad retirement benefits. You are not required to provide the information requested by this form.
However, you are required to report information to the RRB that could affect your eligibility to receive benefits. Your
failure to provide us with the requested information may result in our being unable to pay you any benefits.
We estimate this form takes an average of 20 minutes per response 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 - Instructions
Type or print all answers in ink. If you are completing this form on behalf of someone else, you must answer each
question as it applies to that person. If you need more space than is provided to answer a question, use the Remarks
section on page 7, or a separate sheet of paper. If you do not know the answer to a question, print “Unknown” in the
space provided for the answer.
Look over the information entered by the RRB for Items 1 through 6 to be sure it is correct. If it is correct, go to Section
3. If the information is not correct, line it out and enter the correct information.

Section 2 - Identifying Information
1.
2.
3.
4.
5.

Railroad Employee’s Name
RRB Claim Number
Your Name (If different from Item 1)
Your Social Security Number
Your Mailing Address
City, State, ZIP Code
,

Your Daytime Telephone Number

(

)
Section 3 - Your Work and Earnings

Enter the name, address, telephone number and a brief description of the business or businesses with which you
were or are involved. If there were multiple businesses, describe in the Remarks section on page 7 or use a
separate sheet of paper.
Name of Business
Business Address
Business Telephone Number
Description of Business

Page 1

RRB Form G-252 (04-17)

Enter an “X” in the appropriate box to indicate the form of business that you are involved in.

 Corporation
 Other (Describe):
9.

 Partnership

 Sole Proprietorship

 LLC

Enter an “X” in the appropriate box or boxes:

 IF you perform work, including 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.).

 IF you are a corporate officer of, own, or operate a corporation (including a corporation owned by a family
member or friend) whether for pay or not.

 IF you receive anything of value in lieu of salary or wages for any work that you perform.
 Other (Describe):
10.

Provide a breakdown of how many employees work full-time and part-time in
the business.

Full Time

Part Time

Only complete Items 11 and 12 below if this box is checked; otherwise, go to Section 4.
11.

Enter a monthly breakdown of the
amount of time you spent in this
employment in
.
If regular business hours varied during
certain months of the year, state the
reason for variance(s) (i.e., vacation,
sickness, etc.) in the Remarks section
on page 7.

12.

Enter gross wages or a monthly
breakdown of your net earnings after
deduction of allowable business
expenses under each month of this
employment performed in
.

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEPT

OCT

NOV

DEC

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEPT

OCT

NOV

DEC

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEPT

OCT

NOV

DEC

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEPT

OCT

NOV

DEC

Page 2

RRB Form G-252 (04-17)

Section 4 - Self-Employment

 Yes - Go to Section 5  No - Go to Item 14

13.

Is your business incorporated?

14.

MO
DAY
YEAR
MO
DAY
YEAR
Enter the beginning date and
FROM
TO
ending date (if applicable) of
your self-employment.
List and describe the duties which you performed in the business when your self-employment began (date in Item
14). Include your specific responsibilities, decisions that you made, and tasks that you performed. (Continue in
Remarks section on page 7 or on a separate sheet, if necessary.)

15.

16.

Did you receive any other income, payments, or
reimbursements from the business referenced in
Item 7?

Indicate the type of income and enter the amount.

 Yes - Go to Item 16b  No - Go to Item 17

 Salary $
 Dividends $
 Payment of Loans $

 Rent $
 Bonuses $
 Expense Account $

 Other (List other income and amount):

17.

18.

Yes - Go to Item 17b

No - Go to Item 18

Did you make management decisions?

Describe the kinds of decisions you made, the time spent making them, and how those decisions impacted
the business.

Did you receive any help performing your usual duties?
a

Enter the number of assistants that you had.

Enter the number of hours each day the assistant(s)
devoted to helping you. If you had more than one
assistant, enter a combined total.

Describe the duties of the assistant(s).

1. Was the assistant(s) paid?

 Yes - Go to Item 18a  No - Go to Item 19

_____________________________ hours a day

Yes - Go to Item 18d(2) No - Go to Item 18e

2. Enter the total amount the assistant(s) was paid per
year.
Page 3

RRB Form G-252 (04-17)

18.

Yes - Go to Item 18e(2) No - Go to Item 18f

1. Was the assistant(s) related to you?

2. How was the assistant(s) related to you (i.e., wife, husband, brother, etc.)?

19.

Explain why the additional help was needed.

Has there been a change in your self-employment work
activities since the beginning date in Item 14?

Enter the date of the change in your self-employment work
activities.

Yes - Go to Item 19b
MO

DAY

No - Go to Item 24
YEAR

20.

List and describe your duties beginning with the date in Item 19b. Include decisions that you make, any
consultation provided, and authority that you still hold (i.e., signing of checks, dealing with other businesses as a
representative of the business, making decisions, etc.). Describe how your responsibility has changed since the
date in Item 14. (Continue in Remarks section on page 7 or on a separate sheet, if necessary.)

21.

Have you received income from the business since the
change in your work activities?

Indicate the type of income and enter the amount.

 Salary $
 Dividends $
 Payment of Loans $
 Other (List other income and amount):
22.

23.

Yes - Go to Item 21b

No - Go to Item 22

 Rent $
 Bonuses $
 Expense Account $

Yes - Go to Item 22b

No - Go to Item 23

Do you make management decisions?

Describe the kinds of decisions you make, the time spent making them, and how those decisions impact the
business.

Do you still receive help performing your usual duties?

Yes - Read Note below No - Go to Item 24

Note: If the information in Item 18a-f is still accurate, enter an “X” in the box   and go
to Item 24. Otherwise, complete Items 23a-f.
a

Enter the number of assistants that you have.

Enter the number of hours each day the assistant(s)
devotes to helping you. If you have more than one
assistant, enter a combined total.
Page 4

_____________________________ hours a day

RRB Form G-252 (04-17)

23.

Describe the duties of the assistant(s).

1. Is the assistant(s) paid?

Yes - Go to Item 23d(2) No - Go to Item 23e

2. Enter the total amount the assistant(s) is paid per
year.
e

Yes - Go to Item 23e(2) No - Go to Item 23f

1. Is the assistant(s) related to you?

2. How is the assistant(s) related to you (i.e., wife, husband, brother, etc.)?

Explain why the additional help is needed.

Section 5 - Incorporated Business
24.

Has your business been incorporated?

Enter the date of
incorporation and the
end date, if applicable.

 Yes - Go to Item 24b  No - Go to Section 6
MO

DAY

YEAR

FROM

DAY

YEAR

 Yes

 No

25.

Were you a corporate officer or related to a corporate officer?

26.

Enter each position that you have held
or are holding in the corporation.

27.

Provide the following information to identify the corporate officers at the time of incorporation (date in Item 24b).
NAME

RELATIONSHIP
TO YOU

SALARY

PERCENTAGE OF
STOCK OWNED

President
Vice-President
Secretary
Treasurer

28.

Is anyone who is related to you by blood or marriage
receiving remuneration from the corporation other than
salary?

 Yes - Go to Item 28b  No - Go to Item 29
Name
Relationship

Enter their name and relationship and the type of
remuneration and the amount.

Remuneration Type
Amount

Page 5

RRB Form G-252 (04-17)

29.

Has there been a change in your work activities since
incorporation?

 Yes - Go to Item 29b  No - Go to Item 30
MO

DAY

YEAR

Enter the date the change occurred.

Enter your current position in the corporation.

Provide the following information to identify the corporate officers since the change (date in Item 29b). If the
information is the same as in Item 27, enter an “X” in the box   and go to Item 30. Otherwise, complete
this item.
RELATIONSHIP
PERCENTAGE OF
NAME
SALARY
TO YOU
STOCK OWNED
President
Vice-President
Secretary
Treasurer

30.

Who determines what payments (salary, dividends, etc.) will be made to the corporate officers?
Name
Title
Relationship to You

Section 6 - Ownership of Business
31.

Have you sold or transferred ownership of the
business or leased your farmland?

Enter the sale, transfer, or lease date.

 Yes - Go to Item 31b
MO

32.

33.

34.

35.

 No - Go to Section 7
DAY

Enter the name of the person(s) to whom the business or
farmland (or the interest in the same) was transferred or
rented.
a Is the person(s) named in Item 32 related to you by
 Yes - Go to Item 33b
blood or marriage?
b How is the person(s) related to you (i.e., wife, husband, brother, etc.)?

YEAR

 No - Go to Item 34

Is there a bill of sale, rental agreement, or other transfer
document?

 Yes - Go to Item 34b  No - Go to Item 35

Has the transaction been recorded?

 Yes - Go to Item 34c  No - Go to Item 35

Enter where the transaction has been recorded.

Will you participate in any capacity in the operation of
the business or farm after the transfer?

Explain how you will participate.

Page 6

 Yes - Go to Item 35b  No - Go to Item 36

RRB Form G-252 (04-17)

36.
37.

Enter the price that the new owner or partner paid for the
transferred interest in the business.
a Will you receive any income under the transfer
arrangement?

Amount

 Yes - Go to Item 37b

 No - Go to Section 7

Amount

Enter the amount and type of income you will receive.

Type

Section 7 - Remarks
38.

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 any additional information
that you feel may be important to include.

Section 8 - Certification
39

I have submitted all requested information. I know that if I make a false, misleading, or fraudulent statement in
order to receive benefits from the Railroad Retirement Board (RRB), I am committing a crime which is punishable
under Federal law. I certify that the information I gave the RRB on this questionnaire is true to the best of my
knowledge.
Signature

Date

Page 7

RRB Form G-252 (04-17)

File Type	application/pdf
File Title	G-252 (04-17)
Subject	Form Approved OMB No. 3220-0202
Author	dmh
File Modified	2017-04-24
File Created	2017-04-24