DISABILITY EARNINGS REPORT



EMPLOYEES' RETIREMENT 5¥ STEM

OF THE

GOVERNMENT OF THE VIRGIN ISLANDS

48B-50C Kronprindsens Gade

Charlotte Amalie, St. Thomas, U. 5. V. 1. 00802

Phone #809-776-7703 Fax # 809-776-4499



INSTRUCTIONS:



(1) If you received a disability pension for the entire calendar year, indicate any

and all earnings from gainful employment.



(2) If you retired with disability pension during the calendar year, indicate only

those earnings from gainful employment hfter your retirement date.



(3) If you had no earnings, indicate "NONE" in the space provided.



TO THE BOARD OF TRUSTEES:



In accordance with the provisions of Title 3, Chapter 27, Section 711 (b) of the Virgin Islands

Code (as extracted below) |, the undersigned do swear and affirm that while receiving my disability



annuity, | earned $ in the calendar year from gainful occupation.

Social Security No. — Name

Date Signature a

Street or P. QO. Box No. i City, State & Zip Code



Extract from Title 3, Chapter 27, Section 711 (b). Virgin Islands Code:



"Should any member receiving a duty disability annuity or non-duty disability annuity resume a gainful

occupation, and his earnings therefrom together with his disability annuity exceed the rate of

compensation of the member at the date of retirement, the Board shall reduce the amount of disability

annuity to an amount which, when added to the compensation being carned by the member, shall not

exceed the rate of compensation of the member at the date he last became a disability beneficiary."



On this _day of | personally appeared before me the above named

who is known to me and who subscribed the foregoing

statement before me and made oath that the foregoing answers each and all complete and truc.



(SEAL) NOTARY PUBLIC