RL-231-F (01-18) Request to Non-Railroad Employer for Information About A

RAILROAD RETIREMENT BOARD

Form Approved
OMB No. 3220-0107

CURRENT

WWW.RRB.GOV

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TOLL-FREE NUMBER: 1-877-772-5772

In reply refer to

The person named above is receiving an annuity under the Railroad Retirement Act (RRA), a
Federal law. Work activity and earnings may affect his (her) entitlement to that annuity.
Social Security records show that you reported wages for this person in the following year(s):
Please furnish the information requested on the next page. Section 7(b)(6) of the RRA authorized
the Railroad Retirement Board (RRB) to gather this information in order to determine if the
employment has any effect on the annuity. If you fail or refuse to furnish the requested
information, non-payment of the annuity to the person named above may result.
We estimate this form takes an average of thirty 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 aspects 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 St., Chicago, IL. 60611-1275.
Please return this form to the RRB in the enclosed envelope. If you need help in completing this
form, contact the nearest office of the RRB.
Sincerely,

Enclosure
Envelope

RL-231-F (01-18)

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

-2-

FORM APPROVED
OMB No. 3220-0107
,

Please provide the information in the items checked below, and sign and date the form before
returning it.
1. Date began employment with you ___________________________________________.
2. Date last in your employ ______________________________. (If still working, so state.)
3. Furnish a monthly breakdown of this person's gross earnings below for each month in your
employ since
. (Include tips and leave payments as earnings. If payment was made
by other than monetary means, such as room or board, please explain in the Remarks
section below.) Do your best to complete all items that pertain to the employee’s earnings.
If you are unsure of the accuracy of the earnings information reported on this form, send a
copy of the requested year’s W-2 or other proof of the year's earnings. We will then
complete the form for you.

January
February
March
April
May
June
July
August
September
October
November
December
Total
Remarks:

4. Other
I acknowledge that knowingly providing false, incomplete, or fraudulent information to the RRB is a
crime punishable by civil and criminal penalties. I certify that the information provided is true,
complete, and correct to the best of my knowledge.
Signature of Employer or Authorized Official

Date

Business Phone
(

)

RL-231-F (01-18)