Annual Earned Income Report (Calendar Year 2015) Page 2

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Report of Earnings
If you did not file a Federal income tax return for calendar year 2015, please check one of the following:
Not required to file (please attach Verification of Non-filing from the IRS)
A
pplied for filing extension (please attach a copy of IRS Form 4868)
Estimated 2015 Annual income $____________________________(must be provided if this box is checked)
 O
ther (explain): _____________________________________________________________________________
Certification
I certify that the information provided on this form is true and correct. I further understand that if I have provided any
materially false information, I will forfeit all rights to my disability retirement annuity. I understand that making knowingly
false or frivolous statements or representations may subject me to civil and criminal penalties under Federal and District of
Columbia laws.
____________________________
________________________
____________
Member’s Signature
Member’s Printed Name
Date
(Must sign in the presence of a Notary Public)
***************************
Notary Public Verification
STATE OF ________________________________________________
COUNTY OF ______________________________________
Before me, a Notary Public, on this day personally appeared __________________________________________________ known to me to be the person whose
name is subscribed to the foregoing instrument and acknowledged to me that s/he executed the same for purposes and consideration therein expressed.
Given under my hand and seal of office this ____________________ day of _______________________, 20____________
(SEAL)
______________________
_________________
Signature of Notary
Commission Expires
900 7th Street, NW, 2nd Floor Washington, DC 20001
Telephone: (202) 343-3272  Toll Free: (866) 456-3272  Fax: (202) 566-5001

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