Form G-19F (Web) Earnings Information Request

FORM APPROVED

OMB NO. 3220-0184

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

EARNINGS INFORMATION REQUEST
(EMPLOYMENT FOR HIRE OR SELF-EMPLOYMENT)
See Completion Instructions on next page.
1. Did you work for yourself or someone else?
YES - Enter the latest two calendar years worked ­
NO - Go to Item 5
2. If self-employed enter an “X” in this box
Item 3.

and go to

Otherwise, enter the name and address of your
employer and your employer’s Federal tax ID or
employer identification number.

Employer Name

Address

City, State, ZIP Code

Tax ID/EIN

3. Enter your total gross earnings from employment for hire or your total net earnings from self-employment for
each year that you listed in Item 1 above.
Calendar Year

Total Annual Earnings $_____________________

Calendar Year

Total Annual Earnings $_____________________

4. Enter the last two calendar years in the red boxes below. Also enter in each month, the gross amount
earned in employment for hire or, if you are reporting self-employment, the net amount earned and the hours
and
worked. Note: If your earnings and/or hours of work were the same in each month, check this box
go to Item 5.
Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Earnings
Hours

Earnings
Hours

5. Do you expect to work for yourself or anyone else this year?

YES

NO

YES

NO

If “Yes,” enter estimate of earnings. _______________________________
6. Have you stopped working or will you stop working within 90 days?

If “Yes,” enter date you stopped or will stop working if it is within 90 days. ___________________________

7. REMARKS: ____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
NOTICE: I certify that the information I am giving is true, complete and correct. I understand that criminal and
civil penalties may be imposed on me for false or fraudulent statements.
Signature

Date

Print Name

RRB Claim Number

Telephone Number

Street Address

City, State

ZIP Code

Return the completed form to the nearest office of the Railroad Retirement Board.
Click here to locate the nearest RRB office.
G-19F (Web) (2-18)

INSTRUCTIONS FOR COMPLETING FORM G-19F

The Railroad Retirement Board (RRB) requires earnings information to determine the amount of benefits you
are entitled to for certain years. You may use the attached form to report earnings up to two years. Complete
another form if you need to report earnings for more than two years.
If you have any questions about the form, or need additional information, please contact the nearest office of the
RRB. Click here to locate the nearest RRB office.
Item 1 - Enter the calendar years that you worked for yourself or someone else. Otherwise go to Item 5.
Item 2 - If you are self-employed enter and X in Item 2 and go to Item 3.
Otherwise, enter the name and address of your employer and your employer’s Federal Tax ID or
Employer Identification Number. These can be found on your Form W-2
Item 3 - Enter your total net earnings from self-employment or your total gross earnings from employment for
hire for each year that you listed in Item 1.
•

If you were self-employed, use your income tax returns or business records to get the net amount
of your self-employment earnings.
Furnish copies of your Schedule SE, Form 1040, for the year(s) indicated.

•

If you or your family has incorporated a business, report your earnings as wages, not selfemployment.

•

If you were employed by someone else, report your total wages before payroll deductions (even if
some of your wages were not covered under the Social Security Act).
Furnish copies of your Forms W-2 for the year(s) indicated.

Item 4 - Enter the calendar year in the red box. Enter your earnings and the hours you worked in each month.
If your earnings and/or hours of work were about the same in each month (including months you were
on vacation, were sick or injured, or were on continuation of pay) check the box.
Item 5 - If you plan to work for yourself or any other employers this year, provide an estimate of those earnings.
Item 6 - If you have stopped working, enter the date you were last employed. Or, enter the date you plan to stop
working, if it is within 90 days.
Item 7 - Remarks - Self-explanatory.
Paperwork Reduction Act and Privacy Act Notices
The Railroad Retirement Board is authorized to collect the following requested information under section 7(b)(6)
of the Railroad Retirement Act (RRA). This information is needed to determine if your earnings affect payment
of your railroad retirement benefits. You are not required to provide us with the information requested by this
form. However, we may not be able to pay you benefits if you fail to provide us with this information. The
information you provide may be disclosed for purposes of verification to the employers you name in this report.
We estimate this form takes an average of 8 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 the completion time, to the Associate Chief Information Officer for
Policy and Compliance, Railroad Retirement Board, 844 N. Rush St., Chicago, IL 60611-1275.

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