AA-3 (proposed) Application for Spouse/Divorced Spouse Annuity

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

u,
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FORM APPROVED
OMB NO. 3220-0042

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DO NOT WRITE IN 'THIS SPACE

OFFICIALLY FILED

OFFICE NUMBER

APPLICATION FOR
SPOUSEIDIVORCED
SPOUSE ANNUITY

APPROVED

DATE CODED
MONTH
DAY

APPLICATION NUMBER

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YEAR

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CODED BY

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General Instructions
Before you complete this application, be sure to read the booklet RB-30, Spouse/Divorced Spouse Annuity, which explains information
you will need to answer many of the questions in this application. Also be sure to read the important notices a t the end of the booklet
RB-30.
Type or print legibly in ink. If you need more space than is provided to answer a question, use Section 15 for this purpose. If you do not
know the answer to a question, print "Unknown" in the space provided for the answer.
When entering dates, always use numbers. Also, be sure there is one number in each box. For example, you would enter June 6,2007, as:
Month

Day

Year

016 0 6 2101017
Some items in this application will not apply to you so you will not need to answer them. Based on your answer to a question, you may
be told to skip to another item number, or even another section. Follow the instructions that tell you to "Go to" another item. These are
designed to save you time and help you move through the application form quickly filling in only necessary information. If no "Go to"
instructions are given, answer the next item in order. Do not skip any items unless directed to do so.

If you are completing this application on behalf of someone else, you must answer each question as it applies to the applicant.

Identifying Information
Check the information entered by the Railroad Retirement Board (RRB) for Items 1 through 6 for accuracy.
If the information is correct, go to Section 3.
If the information is not correct, cross out the incorrect information and enter the correct information above it.
If the information is missing, fill it in.

*

Employee
Identification

1

1 1

EMPLOYEE'S SOCIAL SECURITY NUMBER

131

EMPLOYEE'SNAME

4

APPLICANT'S NAME

5

a

2

1

EIWPLOYEE'S RAILROAD RETIREMENT CLAIM NUMBER

1 1

6

-

A

MAILING ADDRESS
CITY AND STATE

b

-1
-

-

ZIP CODE

>

COUNTY

>

DAYI'IME 'TELEPHONE NUMBER

/

Form AA-3 (XX-XX) Destroy Prior Editions

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Social
Securitv

7

Information About You And Your Family
Enter your social security number.

Enter an "X" in the appropriate box:
My name appears on my social security card
exactly as it does in ltem 4.
Enter your name as it appears on your
social security card.

11 11 11

10 Enter an "X" in the box that shows your sex.

Sex

a

-a
*

11 Enter your date of birth.

1

1 1

Go to
ltem 8

-

-

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Yes

-t

No

+ Go to ltem 9

FEMALE

Month

Day

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Month

Day

Year

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1 13

different from Item 4.

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Enter the date of your marriage
to the railroad employee.

*

Enter an "X" in the appropriate box:
Marital status to the railroad employee.

*

a
a
a

15 Enter an "X" in the appropriate box:

Previous
Marriage

The railroad employee was married
before our marriage.

--

I was married before my marriage
to the railroad employee.

a
a
a
a

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Subsequent 17 Enter an "X" in the appropriate box:
Marriage
I was married after my marriage

*

to the railroad employee.
Marriage
History

Year

MARRIED + Go to Item I 5
DIVORCED + Go to ltem 17
Yes

LI No

16 Enter an "X" in the appropriate box:

Yes
No

+ Go to Item 18
+ Go to ltem 19

yes
No

18 If you are a spouse, enter the following information about your marriage before your marriage to the employee.

If you are a divorced spouse, enter the following information about your marriage after your marriage to the
employee. If applicable, enter information for more than one marriage in Section 15.
Marriage Ended

Marriage Began

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1. Date

5. Date

2. City and State

6. City and State

3. Former Spouse's Name
4. Former Spouse's Social Security Number

-

7. Reason

a Death a Divorce a Annulment
a Other - Explain in Section 15
-

-

Complete 18b if you do not know your former spouse's social security number.
b

Month

Enter your former spouse's
(1) Date of birth

*

I ( (2) Place of birth
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I I / Father's name
1 I 1 Mother's maiden name

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(3)

(4)

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12 Enter your name at birth if

tdarne At
Birth
Current
Marriage

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Go to Item 10

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Form AA-3 (XX-XX)

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Page 2

Day

Year

Criminal
Offense

Enter an " X in the appropriate box:
Within the past I 2 months, I have been imprisoned or given a sentence of
confinement due to a conviction for a
criminal offense.

a Yes + Go to Item 20

a

--

-

20 Enter the date of the conviction.

Enter the date of the sentence of
confinement.

Enter the date that confinement began.

t

Enter an "X" in the appropriate box:
Has the confinement ended?

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No + Go to Section 4

Month

Day

Year

Month

Day

Year

Month

Day

Year

a
a

Yes + Go to ltem 24
No + Go to Section 4

Month

Day

Year

24 Enter the date confinement ended.

lnformation About Type Of Annuity

1
1

Please read Parts I & Ill of the RB-30 booklet for information about spouse and divorced spouse annuities and reductions for
early retirement.

a
a

Type of

-

Enter an "X" in the box that shows the type of
spouse annuity you are filing for.

a
a
a

Enter an "X" in the appropriate box:
I will accept a reduced age ar~nuityif
I am not eligible for a full age annuity
or an annuity based on child(ren).

ANNUITY BASED ON
CHILDREN

}

REDUCEDAGE
ANNUITY

}

FULL AGE ANNUITY

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no: : :

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DIVORCED SPOUSE
WITH PREVIOUS
AGE REDUCTION

Yes

a No

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lnformation About Children In Your Care

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Filing
Based On
Child-lnCare

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Please read Part I of the RB-30 booklet for an explanation of "child-in-care."
Enter an " X in the appropriate box:
I have one or more of the railroad employee's
children in my care who are unmarried and under
age 18. (This includes natural cl-~ildren,adopted
children, stepchildren and dependent
grandchildren.)
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a
a

NO

+ GO to ltem 33

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Page 3

Yes + Go to ltem 28

Form AA-3 (XX-XX)

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Print the requested information for every child in your care who would count toward qualifying you for an annuity.
Print the youngest child in 28, the second youngest in 29, and so on. If a child does not have a social security
number, enter "TO BE SUBMITTED."
Relationship to Employee
(Check One)

Child's Full Name and
Social Security Number

28~1Name

2

8

29a

b

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29c
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Name

31c
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Name

32b

32c
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Natural
Adopted
Stepchild
Grandchild
Other
Natural
Adopted
Stepchild
Grandchild
Other
Natural
Adopted
Stepchild
Grandchild
Other

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Date of Birth

Natural
Adopted
Stepchild
Grandchild
Other
Natural
Adopted
Stepchild
Grandchild
Other

30~
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31b
32a

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Name

30b
31a

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Name

29b
30a

28c

Enter an " X in the
appropriate box:
The child is disabled

Month

Day

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1 1

n
h
2
;t;l

Day

1

n
3
h
;tl;

Month

Year

Yes

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Day

Day

1

Year

29e

Year

I3Oe

yes

a Yes
a Yes

Year

a

No

32e

32d
Month

Day

Year

Yes

a

No

Note: To support your entitlement to a spouse annuity based on having a disabled child in your care,
either you or the employee must complete and return to the RRB Form AA-1Sa, Application for
Determination of Child's Disability, for each disabled child listed in ltems 28-32.
Do not complete ltem 33 if every child in items 28-32 is living with you; go to Section 6.
Children
Not Living
With
Applicant

33 Print the requested information for every child not living with you. Print the youngest child in (a).
Explain your parental responsibilities in Section 15.
Full Name
Of Child

(

Note: ltems 34-45 are reserved.

Person With Whom Child Now Lives
Child's Address

Relationship
To Child

Name

)

Information About Your Railroad Work

I Please read Part II of the RB-30 booklet for an explanation of work that you must stop.
Railroad
Work
Last
Railroad
Employment

48 Enter your payroll name and identification
number for that employer. (If you did not
work for the employer named in lteni 47 this
year or last year, leave this item blank.)

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-

46 Enter an "X" in the appropriate box:
I have worked for a railroad or other en-~ployerin the
railroad industry or a railroad labor organization.
47 Enter the name of the railroad company or railroad
labor organization that last employed you.

49 Enter your last job title for that employer.
(If you did not work for the employer named
in ltem 47 this year or last year, leave this
I I item blank.)
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Form AA-3 (XX-XX)

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Page 4

m Yes
m No

tGo

to ltem 47

tGo

to Section 7

Enter your last division or department
and its location for that employer.

Employment

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1 51 1 Enter the dates you worked for that employer. I

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(If your railroad emp~~yment
has not endeb,
enter 'the last date you will work for that
employer in the "TO" date.) -------------,

Enter an "X" in the appropriate box:
I relinquish my seniority rights and all other
rights to work for the employer shown in ltem 47
as of the last date entered in Item 51.
Other
Railroad
Work

Year

Day

a

>

-

Enter the name of that employer.

w

Enter your payroll name and Identifica,l:ion
number for that employer.

>

Enter your last job title for
that employer.

w

Enter your last division or department
and its location for that employer.

>

a
a

Year

Day

No

Yes

t Go

to ltem 54

No + Go to ltem 60

TO

FROM

-a
a
-a
Month

Day

Enter an "X" in the appropriate box:
I relinquish my seniol-ity rights and all other
rights to work for the employer shown in
ltem 54 as of the last date entered in ltem 58.
Railroad
Seniority
Rights

1

TO
Month

Yes

Enter an "X" in the appropriate box:
I have worked for ano,ther railroad or other
employer in the railroad industry or a railroad
labor organization this year or last year.

58 Enter the dates you worked for the employer
named in Item 54. (If your railroad employment
has not ended, enter the last date you will work
for this employer in the "TO" date.)

I

FROM
Month

Enter an "X" in the appropriate box:
I still have seniority rights or other rights to return
to work for a railroad err~ployeror a railroad labor
organization not listed in ltems 47 or 54.
Enter the name and address of any additional
employer indicated in ltem 60 with whom you
still have rights to return to work.

Year

Month

Year

Day

Yes
No

Yes

t Go

to ltem 61

No + Go to Section 7

>

Your spouse annuity cannot begin until you relinquish your rights to employment
with the employer(s) named in ltems 47-61.

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Page 5

Form AA-3 (XX-XX)

Do not complete this section if you are filing for a divorced spouse annuity.
Nonrailroad
Work

Please read Part IV of the RB-30 booklet for information about nonrailroad work and how employment affects your
annuity.
62

/

Enter an " X in the appropriate box:
I worked for pay outside the railroad industry within the 6
months before the date I expect my annuity to begin. (Do
not include self-employment. Include any employment for
an incorporated business which you own or public service.) --,

a
a

Yes + Go to Note and Item 63
No

+ Go to Item 73

/ Note: If you had Last Pre-Retirement Nonrailroad Employment (LPE) after your annuity would begin, \
complete Form G-19c Earnings Information Request, only when one of the following applies:
(1) The annuity beginning date (ABD) is before January 1 of this year or
(2) the ABD is January 1, or later, of this year, and you ceased working in LPE after the ABD month/
Most Recent
Nonrailroad
Work

Enter the name and address of your current or most
recent nonrailroad employer.

t

Enter your current or most recent job title
for that employer.

w

Enter your average monthly salary for that employer.
(SHOW DOLLARS ONLY)
Enter the dates you worked for that
en-~ployer.(If you have not set the date
you expect to stop working, leave the
"TO" date blank and check the box
"I am still working.")

-

a I am still working

Enter an " X in the appropriate box:
The employer named in ltem 63 is a seasonal employer. --,
Next Most
Recent
Nonrailroad
Work

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-

68

Enter the name and address of your next most
recent nonrailroad employer within the 6 months
before the date you expect your annuity to begin.

69

Enter your last job title for that employer.

*

Enter your average monthly salary for that employer.
(SHOW DOLLARS ONLY)

*

1

If none, enter "NONE" and go to ltem 73

FROM
Month D a y

Enter the dates you worked for that
employer. (If you have not set the date
you expect to stop working, leave the
"TO" date blank and check the box
"I am still working.")

t

Enter an " X in the appropriate box:
The employer named in ltem 68 is a seasonal employer. --,

Year

TO
Month D a y

a I am still working

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SelfIf you are employed and your business is incorporated, answer Item 73 "No. " Make sure Items 62-72 are also
Employment completed. If your business is not incorporated, answer ltem 73 'Yes and go to ltem 74.
JJ

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Enter an "X" in the appropriate box:
I was self-employed during the last
6 months.

Yes + Go to Item 74
No

+ Go to Section 8

Note: If answered 'Yes, "complete and return Form AA-4, Self-Employment and Substantial Service
Questionnaire, to the RRB.
Form AA-3 (XX-XX)

Page 6

Year

m Yes Go to Section 8
.- m NO + GO to ltem 75

SelfEmployment 74 Enter an "X" in the appropriate box:
I am still self-employed.
(Cont.)

-+

Month

75 Enter the date you were last
self-employed.

Year

Day

w

Information About When Your Annuity Will Begin
Please read Part II of the RB-30 booklet to find out how your annuity beginning date is determined.
Annuity
Beginning
Date

76 Enter an "X" in the appropriate box:
I want my annuity to begin on the
earliest date permitted by law.

*

1 1

77 Enter the date you want your annuity to begin.

m Yes + Go to Section 9
m NO + GO to Item 77
Month

Year

Day

lnformation About Your Earnings
Before answering Items 78-90, please read Part IV of the RB-30 booklet to find out how earnings can affect your annuity.
For the exerrlpt amounts, refer to Form G-77a, How Work Affects Your Railroad Retirement Benefits.
Earnings
Last
Year

*

m Yes Go to Item 79
m No + Go to ltem 83

79 Enter an "X" in the appropriate box:
My total earnings from all employment
last year were more than the annual
earnings exempt amount.

*

m Yes
m No

80 Enter your total earnings for last year.
(SHOW DOLLARS ONLY)

*

78 Enter an "X" in the appropriate box:
I expect my annuity to begin before
January 1 of this year.

t

II
1

1

Yes

*1

82 Enter an "X" next to each month last
year in which you did not earn more than
the monthly earnings exempt amount or perform
substantial services i r i self-employment.

-

Earnings
This Year

83 Enter an "X" in the appropriate box:
I expect my total earnings for all employment this year
to be more than the annual earnings exempt amount. (If
all your earnings are 'from 01-lly railroad en-~ployment
before your date last worked, answer "No.")

(Year)

84 Enter the total amount you expect
to earn this year.
(SHOW DOLLARS ONLY)
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-+

to ltem 80

Go to Item 83

$

1 81 1 IEnter
an "X" in the appropriate box:
earned more than .the monthly earnings exempt
amount in employment for hire or performed substantial services in self-employment in every month
last year.

t Go

-

m No
r
~ 1~

t Go

to ltem 83

+ Go to ltem 82

-

-

p

%

r - p - - - - p q

m Yes
m No

t Go
-+

to Item 84

Go to ltem 87

$

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Page 7

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Form AA-3 (XX-XX

85 Enter an "X" in the appropriate box:

Earnings
This Year
(Cont.)

Earnings
Next Year

>

Enter an "X" next to each month this year in which
you did not, or do not expect to, earn the monthly
earnings exempt amount or perform substantial
services in self-employment.

>

87 Enter an "X" in the appropriate box:

I am filing this application in
September, October, November, or December.

(Year)

m Yes + Go to ltem 87
m No + Go to ltem 86

I expect to earn more than .the monthly earnings
exempt amount in employment for hire or to
in
perform substantial services in self-employment
.
every month this year.

-

Enter an "X" in the appropriate box:
I expect my total earnings for all employment
next year to be more than this year's annual
earnings exempt amount.

*

Enter the total amount that you expect
to earn next year.
(SHOW DOLLARS ONLY)

>

1 90 1 Enter an "X" next to each of the first four
1 1

m Yes + Go to ltem 88
m No Go to Section lo

-

m Yes + Go to ltem 89
m No Go to Section 10

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months of next year in which you expect
to earn less than this year's monthly
earnings exempt amount.

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Information About Social Security Benefits
Please read Part V of the RB-30 booklet to see how this application can protect your rights to social sec~~rity
benefits, and to see what effect social security benefits will have upon your railroad retirement annuity.
Social
Security
Filing Date

Enter an "X" in the appropriate box:
I also want this application used to protect my filing
date for social security benefits. (Answer "Yes" only
if you are age 62 or older, disabled, or otherwise
eligible for social security old age, disability, or
survivor benefits and you have not filed an application for such benefits.)

Yes

- aa
- aa
-

m No

Enter an "X" in the appropriate box:
I have filed, or plan to file within the next 90 days,
an application for social security benefits.

Social
Security
Benefits

Month

93 Enter the date you became or will become

eligible for these social security benefits.

Enter an "X" in the appropriate box:
I have received my first social security payment.

Enter the current total monthly amount of
your social security benefits (before
reduction for work or Medicare premiums).
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Form AA-3 (XX-XX)

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Page 8

Yes + Go to ltem 93
No + Go to Section 11
Year

Yes + Go to ltem 95
No + Go to ltem 96

Social
Security
Benefits
(Cont.)

Enter an "X" in the appropriate box:
All or part of my social security benefits
described above are based on the earnings
of someone other than the railroad
employee or myself.

1 1

a
a

Yes

-

Go to ltem 97

No -+ Go to Section II

t

-1
-

97 Enter the social security number of the person on whose

earnings your social sea-~ritybenefits are based.

Enter the name of the person on whose earnings
your social security benefits are based.

lnformation About Other Railroad Retirement Annuity
Please read Part V of the RB-30 booklet for an explanation of the reduction for other railroad retirement annuities.
Enter an "X" in the appropriate box:
,
I previously filed, or I ani now ,filing for a
separate railroad retirement annuity based
on an earnings record of someone other than
the railroad employee named in ltem 3.
(Include yourself if applicable.)

Other
Railroad
Annuity

Print the full name of that other person.

a
a

No

*

-

-+

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Go to ltem 100
Go to Section I 2

If only six numbers,
enter here:

Prefix

I101 Enter that other person's Railroad

Retirement Board claim number,
including the letter prefix.

Yes

>

lnformation About Public Service Pension
Please read Part V of the RB-30 booklet for an explanation of the reduction for a Public Service Pension.
Public
Service
Pension

Enter an "X" in the appropriate box:
I am receiving or expect to receive a pension or I
have received or expect to receive a lump-sum
paynient instead of a pension, based on my
earnings, from a agency of the Federal, state,
or local government. (Answer "No" if your only government pension payments are social security,
railroad retirenient, veterans affairs, worker's compensation, or black lung benefits.
Also answer "No" if you received a lump-sum
payment that was just your contributions
to the pension fund plus interest.)

a
a

Yes

+ Go to ltem 103

No

-+

Go to Section I 3

Yes

-+

Go to Note and Section 13

No

-+

Go to ltem 104

-

Enter an "X" in the appropriate box:
I anitwas an employee of the Federal Government. -+

a
a

Note: If answered "Yes, " complete and return to the RRB, Form G-208, Public
Service Pension Questionnaire, and verification of your pension.

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Page 9

Form AA-3

(XX-XX)

104 Enter an "X" in the appropriate box:
On my last day of employment,
I was employed by a state or local
government or the military service, and
social security (FICA) taxes were being
deducted from my public service earnings.

Public
Service
Pension
(Cont.)

/
\
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-

0 Yes
0 No

-)

Go to Section 13
Go to Note and Section I 3

NOTE: If answered 'No," complete and return to the RRB, Form G-208,
Public Service Pension Questionnaire, and verification of your pension.

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Information About Medicare

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Complete this section only if you are 64 years and 5 months of age or older.
Please read Part VI of the RB-30 booklet for an explanation of the Medicare program.
Medicare 105 Enter an 'X" in the appropriate box:
Enrollment
I have a Medicare card that shows entitlement

to Medicare medical insurance (Part B).

b

-

106 Enter your Medicare claim number.
(If this is a railroad retirement filing, enter the prefix.
If it is a social security filing, enter the suffix.)

107 Enter an "X" in the appropriate box:
I have filed for Part B within
the last three months.

t

108 a Enter the social security number or railroad retirement claim number under which you filed. (If this
is a railroad retirement filing, enter the prefix. If it
is a social security filing, enter the suffix.)

-

b Enter the date you filed.

b

Enter an "X" in the appropriate box:
I wish to enroll in Part B.

*

0 Yes -+ Go to ltem 106
0 No -+ Go to ltem 107

Go to Section 14

0 Yes -+ Go to ltem 108a
0 No -+ Go to Item 109

Month

I
m

-m
m
-

111 Enter an "X" in the appropriate box:
I was previously covered by an EGHP based on my
own or my spouse's current employment.

/

If applicable, the date employment will stop for the
person whose employment qualifies me for EGHP
coverage is:
F o r m AA-3 (XX-XX)

Page 10

Day

Month

P

Year

I
Yes + If you are under age 65 years
and 4 months, go to section 14.
If you are older than age 65 years and 3
months, go to ltem 110.
No + I understand that I elected not to
enroll in Part B and that the premium rate
may be higher if I do enroll later in Part B.
Go to Section 14.

0 Yes
0 No

1112 The beginning date of my EGHP coverage is:

Suffix

Prefix

m
110 Enter an "X" in the appropriate box:
I am currently covered by an employer group health
plan (EGHP) based on my own or my spouse's
current employment.

Su.ffix

Prefix

-+Go to Item 112
-)

Gotoltemlll

Yes

-)

Goto ltem 113

No

-)

Go to Section 14

Day

Year

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Medicare
Enrollment
(Cont.)

The beginning and ending dates of my EGHP
coverage and the date last worked in the employment
which qualified me for EGHP coverage are:

1

Month

I

Day

1

Year

1

EGHP Beginning Date
EGHP Ending Date
Date Employment Stopped

*J--'J--

D Yes
D No

114 Enter an "X" in the appropriate box:

I wish to enroll in a special enrollment period. ------+
in the appropriate box:
a. I am enrolling in Part B while either still covered by
an EGHP or during the first full month after my
w
EGHP coverage.

-

b. I am requesting a Part B effective date of

Enter an "X" in the appropriate box:
I am requesting premium surcharge relief
for the months of EGHP coverage.

1

D Yes
D No
Month

---

Gotoltem 115a
Gotoltemll6

Gotoltem115b
Go to Section I 4

Day

Year

Go to
Section 14

D Yes

1

Please read Part VII of the RB-30 booklet for an explanation of Direct Deposit.
Benefits are generally paid by Direct Deposit to your bank, savings and loan, credit union, or other financial institution. To provide the information we need to correctly deposit your payments, attach a voided personal check and go
to Section 15, or call your financial institution for the information you need to complete Items 117-121, below. If you
do not have a bank account, or if you believe receiving your payments by Direct Deposit would cause you a hardship,
go to Item 122.
117 Enter the name of your financial institution.

Direct
Deposit

Area Code

118 Enter the telephone number of your

financial institution.

t

119 Enter the routing transit number of your financial institution.

120 Enter your account number.

-

Enter an "X" in the appropriate box:
Type of account for the above account number.

-

Telephone Number

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Checking
Savings
Go to Section 15

Check this box if you do not have a checking
or savings account, or if Direct Deposit would
cause you a hardship.
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Form AA-3 (XX-XX)

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Remarks
123 This section is to be used for the continuation of answers to other items. Be sure to include the item number

Remarks

at the beginning of the answer you wish to continue. You niay also use this section to enter any additional
information that you feel may be important to include.

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Form AA-3 (XX-XX)

Page 12

Certification

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Certification 124 Enter an "X" in the appropriate box:
I will have a guardian or other representative
sign this application on my behalf.

m YES + Go to Note and Item 125
m NO -+ Gotoltem125

Note: If answered "Yesy"your guardian or other representative must sign this application. That
person must also complete and return FormAA-5, Application for Substitution of Payee.
125

1 know that if I make a false or fraudulent statement in order to receive benefits from the Railroad Retirement Board
(RRB), I am committing a crime which is punishable under Federal law. I have received the booklets, RB-30,
SpouselDivorced Spouse Annuity and RB-9, Employee and Spouse Annuities-Events That Must Be
Reported. I understand that I am responsible for reporting events that would affect my annuity as explained in these
booklets. I certify that the information I gave the RRB on this application is true to the best of my knowledge.

I agree to immediately notify the RRB:
IF I go to work for a railroad or railroad labor
organization, or return to work in any capacity in the
railroad industry.
IF I am filing in advance of the date(s) shown in
Item(s) 51 (and 58), and there is a change in a date.

IF I remarry (if I am filing for a divorced spouse annuity).
IF a qualifying child marries or leaves my custody or
residence.

' IF my address changes.
IF I am confned in a jail, prison, penal institution, or correctional facility due to a conviction for a crit-r~inaloffense.

IF I receive a settlement with credit for railroad
service as "pay-for-time-lost" for months after the
date(s) shown in Item(s) 51 (and 58).

IF I earn more than the annual earnings exempt amount.

IF I return to work for my Last Pre-Retirement
Nonrailroad Employer and there is a change in
my estimated earnings.

IF I perform any work, including self-employment, or
volunteer at a family owned business, operated or
owned by me, a family member, friend or close
associate, whether for pay or not.

IF I begin to receive benefits directly from the Social
Security Administration.

IF I become a corporate officer of, own, or operate
a corporation (including a corporation owned by a
family member or friend) whether for pay or not.

IF benefits I receive directly from SSA are adjusted for
a reason other than normal cost-of-living increases.
IF I begin to receive a public service pension or there is
a change in the amount of my public service pension.

IF I receive anything of value in lieu of salary or
wages for any work that I performed.

IF my marriage ends in death or divorce (if I am
filing for a spouse annuity).

Also, if I am covered by the earnings restriction provisions of the Railroad Retirement Act, I have received and
reviewed Form G-77a, How Work Affects Your Railroad Retirement Benefits. Failure to report any of the
above events or other events that may affect my annuity may result in a penalty deduction 'from my annuity,
criminal and/or civil prosecution.

*

SIGNATURE
(First Name, Middle Initial,
Last Name)

Month

Day

Year

*

DATE

--

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126 If this certification is signed by mark ("X") in ltem 125, two witnesses who know the person signing must
sign below, giving their full addresses and daytime telephone numbers.
a. Signature of Witness

b. Signature of Witness

Address (Number and Street)

Address (Number and Street)

City, State, ZIP Code

City, State, ZIP Code

Area Code

Telephone Number

Page 13

Area Code

Telephone Number

Form AA-3 (XX-XX)

How To Return Your Application

Before you return your application, check to make sure that:

*

Every question that applies to you has been answered.

*

You have entered "unknown" in any answer space for which you were unable to answer a question.

*

You have signed and dated the application.

*

You have included all the needed proofs listed in the letter you received with this application.

When you received your application, you should also have received a pre-addressed return envelope. If you
do not have this envelope, you can use any envelope as long as it is addressed to the RRB office shown on
page 15 of this application. No matter which envelope you use, you must put the correct postage on the
envelope. Be careful to provide enough postage, because your application and the accompanying forms may
weigh more than a standard letter. The U.S. Postal Service will not deliver your application unless it has the
correct postage.
Make one final check before you seal the envelope to ensure that the following are enclosed:

*

NEEDED PROOFS

*

THE APPLICATION FORM ITSELF

*

ADDI1-IONAL FORMS YOU WERE ASKED TO COIVIPLE-TE

/ Note: After the RRB receives your application, a receipt form with information about your claim
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will be sent to you. When you receive it, you will know that the RRB has received your application and has started .the work needed to determine if you are entitled to benefits. If you do not
receive the receipt within two weeks after you have filed this application, please contact us so
we can find out what is causing the delay.

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Form AA-3 (XX-XX)

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