Annual Earned Income Report (Calendar Year 2015)

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District of Columbia Retirement Board (DCRB)
Benefits Department
900 7th Street, NW, 2nd Floor Washington, DC 20001
Telephone: (202) 343-3272  Toll Free: (866) 456-3272  Fax: (202) 566-5001
Annual Earned Income Report (Calendar Year 2015)
The District of Columbia Police Officers and Firefighters’ Retirement Plan requires that disability retirement benefit
annuitants under the age of fifty (50) submit a notarized statement reporting earned income for the prior calendar year (DC
Code §5-714). If the space below is not sufficient to report all of your income sources, please submit additional pages. The
deadline for submission of this report is May 16, 2016. If you do not file your report by this date, the District of Columbia
Retirement Board (“DCRB”) will stop your benefit.
YOU MUST ATTACH A COPY OF THE FIRST TWO PAGES OF YOUR IRS 1040 FORM!
If you are married filing jointly, provide copies of all W-2 and 1099 information filed with your tax return.
Member Information
________________________________________________________________________________________
First Name
Middle Initial
Last Name
Date of Birth
Social Security Number
____________________________________________________________________________________________________________________________________
Street Address
City
State
Zip Code
Telephone Number
Income From Wages (Based on W-2 Forms)
Employer’s Name (Do not include disability payments received from DCRB.)
Amount, Box 1 of W-2
1.______________________________________________________________________
$____________________________
2.______________________________________________________________________
$____________________________
Income From Your Personal Business (IRS Form 1040 Schedule C or Schedule C-EZ)
1040 Line 12
—-If you reported below, please attach a copy of the form to this report —-
Name of Business
Amount, Schedule C, Line 31 or C-EZ, Line 3
1.______________________________________________________________________
$____________________________
2.______________________________________________________________________
$____________________________
Income From Partnerships (IRS Form 1040 Schedule E Part II)
1040 Line 17
If you file Schedule E, please send a copy of your tax return.
Name of Partnership
Amount, Schedule E, Line 28
1.______________________________________________________________________
$____________________________
2.______________________________________________________________________
$____________________________
Income From Your Farm or Ranch (IRS Form 1040, Schedule F)
1040 Line 18
Name of Farm/Ranch
Amount, Schedule F, Line 34
1.______________________________________________________________________
$____________________________
Other Income (IRS Form 1040, Line 21)
Name of Payor
Amount, Form 1040, Line 21
1.______________________________________________________________________
$____________________________
2.______________________________________________________________________
$____________________________
DCRBFormAEIR-300
Revised 2/2016

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