RI 30-002_2019_MarkUp

Annuitant's Report of Earned Income for 2019

OMB Approval
3206-0034

Draft

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

III

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. Please report the amount of Earned Income for 2019. 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

1

0

1

Dollars

0

9
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5
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Cents

1

.. 4
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5

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.

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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

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 2019 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
knowledge and belief.
Annuitant's signature
4. Date

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

Previous editions are not usable.

Witness' signature

Date

Witness' address

RI 30-2
Revised January 2020

Instructions
The Office of Personnel Management (OPM) requires you as a Federal retiree who is under age 60 during the survey year
and receiving disability benefits to provide information if you had income from wages or self-employment during 2019. 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 2019 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, 2020. 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
Please report the AMOUNT of WAGES and/or NET EARNINGS from SELF EMPLOYMENT for 2019.
Please report this income if you have done the following:
Worked and earned money after retiring from Federal Service,
Or

Were reemployed by the Federal government and are still employed.
*** Even if you did not have WAGES or NET EARNINGS FROM SELF EMPLOYMENT,
please complete block number 1 with zeros.
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 (Mon-Thur
from 8:00 AM to 4:00 PM, Eastern Time) or (Friday from 8:30 AM to 3:00 PM, ET). If you prefer, you can write us at:
Office of Personnel Management
Retirement Surveys and Student Branch (Added room no.)
Washington, DC 20415-0001
Privacy Act Statement
Pursuant to 5 U.S.C. § 552a(e)(3), this Privacy Act Statement serves to inform you of why OPM is requesting the information on this form. Authority: OPM is authorized
to collect the information requested on this form by 5 U.S.C., Chapter 83, Section 8337 and Chapter 84, Section 8455, which indicates, bar payment of annuity based
on disability to persons under age 60 who, in any calendar year, earn more than 80 percent of the current rate of pay of the position from which they separated for
retirement. Purpose: OPM will use this form to identify persons who may not be entitled to continued annuity benefits. OPM is requesting this information in order to
determine if disability retirees under age 60 have earned income which will result in the termination of their annuity benefits. Routine Uses: The information may be
shared externally as a "routine use" to other Federal agencies and third parties when it is necessary to review your eligibility. For example, OPM may share your
information with other Federal, state, or local agencies and organizations in order to determine benefits under their programs, to obtain information necessary for
continuation of your eligibility for annuity benefits or to report income for tax purposes. OPM may also share your information with law enforcement agencies if it
becomes aware of a violation or potential violation of civil or criminal law. A complete list of the routine uses can be found in OPM/Central 1 Civil Service Retirement
and Insurance Records system of records notice, available at www.opm.gov/privacy. Consequences of Failure to Provide Information: Providing this information to
OPM is voluntary. However, failure to provide this information may result in the termination of your annuity benefits.

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. 20415-0001. 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.