RI 30-002_2022_01MarkUp

OMB Approval 3206-0034

Annuitant's Report of Earned Income for 2021
If the address shown below is not correct, please
show any change next to your address below.

United States Office of Personnel Management
Retirement Surveys & Students, Room 2416
1900 E Street NW, Washington, DC 20415
Claim number

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 2021. 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 zeros as you need. See the example.

Example: If you have earned income, write the full amount in the boxes. For earnings of $9,562.45, you would complete the boxes as
shown below.

Use a Black or Blue Pen to enter earned income.

Example - $9562.45
Dollars

0
2.

0

9

5

Cents

6

2 . 4

5

Are you currently reemployed in the Federal service?
(See #4 on the reverse side of this form.)
No.

Dollars

Cents

.
2b. Appointment type

2c. Grade and step

Yes, complete 2a - 2d.

2a. Dates of reemployment in the Federal service.

2d. Federal agency name and address if #2 is "yes".

From: (mm/dd/yyyy)

/

/

To: (mm/dd/yyyy)

/

/

Warning: Your earnings for 2021 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 it is later found that the income was incorrectly reported, then the annuitant might be at risk of experiencing a
gap in health insurance coverage, if applicable.
3.

4.

By my signature here, I certify that all information given by me
on this form is true and correct to the best of my knowledge and
belief

If signature is by mark "X", a witness must also sign, date, and
enter his or her address below.

Annuitant signature

Witness signature

Date (mm/dd/yyyy)

Previous editions are usable

5.

Daytime phone number
(including the area code)

Date (mm/dd/yyyy)

Witness address

RI 30-2
Revised January 2022

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 2021. 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 2021 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, 2022. 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 2021:
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.
***If you have Wages or Net Earnings From Self Employment, please complete this survey form.

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 FROM FEDERAL SERVICE.
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 (Monday - Friday from 7:40 AM to 5:00 PM, Eastern Time). Hearing impaired users should
utilize the Federal Relay Service by dialing 711 or their local communications provider to reach a Communications Assistant. If you prefer,
you can write to us at:
Office of Personnel Management
Retirement Surveys and Students Branch, Room 2416
1900 E Street, NW
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.

RI 30-2
Revised January 2022