Form AA-3cert Application Summary and Certification

Fonn Approved
OMB 3220-0042

United States of America
R'ailroad Retirement Board

APPLICATION SUMMARY and CERTIFICA'T~ON

Employee's Name
RR Claim No.
Social Security Number
Date of Birth

The following information was either supplied by or verified by you in support of your
application for a (Application Type) under the Railroad Retirement Act. After you have
reviewed the information, make any changes on the summary, initial the change and sign
the certification on the last page. Return the certification and all pages of the surrlrnary to
the RRB.

Applicant Information
Name and Address
Social Security Number
Date of Birth
Daytime Telephone Number
Type of Application Filed
1

You applied for this benefit based on your relationship to the employee and that you
have the following children in your care.
Name

SS Number

DOB

2

You have requested that any payment due you be sent to the following bank
account:
Bank Name
Routing Number
Account Number
Account Type

3

You have requested that any payment due you'be sent to the address shown
above.

RRB Form AA-3cert (07-02)

32948 64790 22000 06051 32704
2600-EE-SS-NO 2601-APPL-TYPE-CD CURRENT DATE AND TIME

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Form Approved
OMB 3220-0042

United States of America

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Railroad Retirement Board

Applicant's Marriages
4

You are currently married to or separated from the employee.

5

You were married before you marriage to the employee.

6

You were not married before your marriage to the employee.

7

You have remarried since your divorce from the employee.

8

You have not remarried since your divorce from the employee.

Felony Information
9

Within the past 12 months you have not been imprisoned or been given a sentence
of confinement for conviction of a felony.

10

Within the past 12 months you have been imprisoned or been given a sentence of
confinement for conviction of a felony.

Other Government Benefits
11

You have filed or plan to file in the next three nionathsfor Social Security benefits on
your own account.

12

You have filed or plan to file in the next three months for Social Security benefits on
the account of:
Name
Social Security Number

13

You have not filed nor do you plan to file in the next three months for Social Security
benefits on any account number.

14

You have not filed nor do you plan to file in the next three months for Social Security
benefits on an additional account number.

15

You are currently receiving a social security benefit.

16

You are not receiving a social security benefit.
RRB Form AA-3cert (07-02)

32948 64790 22000 06051 32704
2600-EE-SS-NO 2601-APPL-TYPE-CD CURRENT DATE AND TIME

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Form Approved
OMB 3220-0042

United States of America
~gilroadRetirement Board

17

In the past month you have filed or plan to file in the next three months for Railroad
Retirement benefits based on your own earnings.
''

18

In the past month you have filed or plan to file in the next three months for Railroad
Retirement benefits based on the account of:
Name
Claim Number

19

In the past month you have not filed nor do you plan to file in the next three months
for Railroad Retirement benefits on any ather account number.

20

You are currently receiving a railroad retirement annuity.

21

You are not receiving a railroad retirement annuity.

22

You are receiving a pension based on your earnings from a Federal, state or local
government agency.

23

You received a lump-sum payment instead of a monthly pension from a Federal,
state or local government agency.

24

You are not receiving nor do you expect to receive a pension or lump-sum payment
based on your earnings from a Federal, state or local government agency.

25

You expect to receive a pension or lump-sum payment based on your earnings from
a Federal, state or local government agency.

Earnings lnformafion

26

Last year your total earnings were $999,999.99

27

Last year your earnings were less than $999,999.99

28

Last year you earned more than $9999 in each man-th.

29

Last year you earned less than $9999 in the following months:
January February March April May June July August September October
November December

RRB F o m AA-3cert
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(07-02)

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32948 64790 22000 06051 32704
2600-EE-SS-NO 2601-APPL-TYPE-CD CURRENT DATE AND TIME

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Form Approved
OMB 3220-0042

United States of America
RQilroad Retirement Board

30

This year you expect your total earnings will be $999,999.99.

31

This year you expect your total earnings will be less than $999,999.99.

32

This year you expect to earn more than $9999 in each month.

33

This year you expect to earn less than $9999 in the following months:
January February March April May June July August September October
November December

34

Next year you expect your total earnings will be $999,999.99.

35

Next year you expect your total earnings will be less than $999,999.99.

Railroad and Non Railroad Work
36 You worked for the following railroad or other employer in the railroad industry.
Railroad Nanie
Date Last Worked
Date Relinquished Rights
37

You have not worked for a railroad or other err~ployerin the railroad industry.

38

You worked fo; the following employers outside the railroad industry.
(Company Name)
(Company Name)
(Company Name)

.

from 99/99/9999 to 99/99/9999
from 99/99/9999 to 99/99/9999
from 99/99/9999 to 99/99/9999

39

You have not worked for an employer outside the railroad industry.

40

You have self-employment during the last 12 months.

Beginning Dates and Filing Dates
41

You requested your annuity begin on the earliest date permitted by law, even if you
will receive a reduced annuity.

42

You have requested your annuity begin on the earliest date permitted by law, as
long as it does not result in a reduced annuity.

43

You have selected mmlddlyyyy for the beginning date of your annuity.
RRB Form AA-3cert (07-02)

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32948 64790 22000 06051 32704
2600-EE-SS-NO 2601-APPL-TYPE-CD CURRENT DATE AND TIME

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United States of America
Rhilroad Retirement Board

Form Approved
OMB 3220-0042

44

This application will protect your filing date for Social Security benefits.

45

You do not want this application to protect your filing date for Social Security
benefits.

Medicare
46

You are enrolled in the Medicare Medical Insurance Plan (Part 6).

47

You wish to enroll in the Medicare Medical Insurance Plan(PaH 6).

48

You do not wish to enroll in .the Medicare Medical Insurance Plan (Part B) at this
time.

49

You are claiming a special enrollment period based on coverage by an employer
group health plan.

50

You are claiming premium surcharge relief based on coverage by an err~ployer
group health plan.

Application for (Application Type - Certification)
Employee's RR Claim Number
Employee's Name
Employee's Social Security Number
Applicant's Name
Applicant's Social Security Number

I certify that the information I have given to the Railroad Retirement Board (RRB) in
relation to this application is true to the best of my knowledge. I know that if I make a
false or fraudulent statement or withhold information, in order to receive benefits from the
RRB, I am committing a crime which is punishable under Federal law.
I have received and reviewed a summary of the information I provided. I understand that I
have an obligation to advise the RRB immediately if there are any errors in the summary I
RRB Form AA-3cert (07-02)

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32948 64790 22000 06051 32704
2600-EE-SS-NO 2601-APPL-TYPE-CD CURRENT DATE AND TIME

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Form Approved
OM6 3220-0042

United States of America
Rhilroad Retirement Board

received, and have made and initialed any corrections on the Summary being returned to
the RRB.

(Only printed if application type is Spouse or Spouse with child.)
I have received and reviewed the booklets RB-30 Spouse Annuity and RB-9 Employee
and Spouse Annuities - Events that Must be Reported. I understand that Iam responsible
for reporting events that would affect my annuity.
I agree to immediately notify the RRB, if
I remarry;
My marriage to the employee ends in death or divorce.
I begin to receive a pension or receive a lump sum payment based on my earnings
from a Federal, state or local government agency;
The amount of my pension based on my earnings from a Federal, state or local
government agency changes;
I file for social sea-~ritybenefits on any person's account;
Benefits 1 receive directly from the Social Security Adrr~ir~istration
are adjusted for a
reason other than normal cost-of-living increases;
I go to work for an employer in the railroad industry;
I am filing in advance and my last date of employment changes.
If I retl~rnto work for
My expected earnings amount changes;
My address changes;
My bank account changes;
A child on whose basis I am entitled to an annuity marries, dies or leaves my care;
I am confined to a jail, prison, penal institution or correctional institution for
conviction of a felony.

Signature (First Name, Middle Initial, Last Name)

Date

If this certification is signed by mark ("X),two witnesses who know the person signing must sign below.

Signature of Witness

Signature of Witness

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Address (Street, City, State and ZIP Code)
RRB Form AA-3cert (07-02)

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Address(Street, City, State and ZIP Code)

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32948 64790 22000 06051 32704
2600-EE-SS-NO 2601-APPL-TYPE-CD CURRENT DATE AND TIME

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United States of America
Railroad Retirement Board

Daytime Telephone Number

RRB Form AA-3cett (07-02)

Form Approved
OMB 3220-0042

(1
Daytime Telephone Number

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32948 64790 22000 06051 32704
2600-EE-SS-NO 2601-APPL-TYPE-CD CURRENT DATE AND TIME