AA-3cert (proposed Application Summary and Certification

Form Approved
OMB 3220-0042

United States of America
Railroad Retirement Board

APPLICATION SUMMARY and CERTIFICATION
Employee's Name
RR Claim No.
Social Security Number
Date of Birth

The following information was either si~ppliedby or verified by you in si~pportof 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 summary 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.

Applicant's Marriages

4

You are currently married to or separated from the employee.
RRB Form AA-3cert (XIC-06)

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

Page 1

Form Approved
OMB 3220-0042

United States of America
Railroad Retirement Board

5

You were married before your 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.

Criminal Offense Information
9

Within the past 12 months you have not been irr~prisoned
or been given a sentence
of confinement due to a conviction for a crirr~inaloffense.

10

Within the past 12 months you have been imprisoned or been given a sentence of
confinement due to a conviction for a criminal offense.

Other Government Benefits
I1

You have filed or plan to file in the next three months for 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.

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

4

RRB Fonn AA-3cert (xx-06)

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

Page 2

Form Approved
OMB 3220-0042

United States of America
Railroad Retirement Board

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 other 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 Information

26

In 9999, (last year) your total earnings were $999,999.99

27

In 9999, (last year) your earnings were less than $999,999.99

28

In 9999, (last year) you earned more than $9999 in each month.

29

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

30

In 9999, (current year) you expect your total earnings will be $999,999.99.

31

In 9999, (current year) you expect your total earnings will be less than $999,999.99.

32

In 9999, (current year) you expect to earn more than $9999 in each month.

33

In 9999, (current year) you expect to earn less than $9999 in the following months:
RRB Form AA-3cert (xx-06)

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

Page 3

Form Approved
OMB 3220-0042

United States of America
Railroad Retirement Board

January February March April May June July August September October
November December
34

In 9999, (next year) you expect your total earnings will be $999,999.99.

35

In 9999, (next year) you expect your total earnings will be less than $999,999.99.

Railroad Work and NonRailroad Work
36 You worked for a railroad or other employer in the railroad industry.
Railroad Name
Date Last Worked
Date Rights Relinquished
37

You have not worked for a railroad or other employer in the railroad industry.

38

You worked for the following employers outside the railroad industry in the 6 months
before you expect your annuity to begin.
(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 in the 6 months
before you expect your annuity to begin.

40

You worked for the following employers as a seasonal employee:
from 99/99/9999 to 99/99/9999
from 99/99/9999 to 99/99/9999
from 99/99/9999 to 99/99/9999

(Company Name)
(Company Name)
(Company Name)
41

You were self-employed during the last 12 months.

Beginning Dates and Filing Dates
42

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

43

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

44

You have selected mmlddlyyyy for the beginning date of your annuity.

RRB Form AA-3cert (xx-06)

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

Page 4

Form Approved
OMB 3220-0042

United States of America
Railroad Retirement Board

45

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

46

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

Medicare
47

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

48

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

49

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

50

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

51

You are claiming premium surcharge relief based on coverage by an employer
grol.ip 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 comrr~ittinga crime which is punishable under Federal law.
I have received and reviewed a summary of the information I provided. I understandthat I
have an obligation to advise the RRB immediately if there are any errors in the Summary I
received, and have made and initialed any corrections on the Summary being returned to
the RRB.
RRB Form AA-3cert (xx-06)

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

Page 5

United States of America
Railroad Retirement Board

Form Approved
OM0 3220-0042

Only printed if application type is Spouse or Spouse with child and spouse is FRA or
older.
I have received and reviewed the booklets RB-30 Spouse Annuity and RB-9 Employee
and Spouse Annuities - Events that Must be Reporfed. I understand that I am responsible
l d my annuity. Failure to report any of the events that
for reporting events that w o ~ ~affect
may affect my annuity, may result in a penalty deduction from my annuity, criminal and/or
civil prosecution.
Printed if application type is Spouse or Spouse with child and spouse is under FRA.
I have received and reviewed the booklets RB-30 Spouse Annuity, RB-9 Employee and
Spouse Annuities - Events that Must be Reporfed and form G-77a How Work Affects Your
Railroad Retirement Benefits. I understand that I am responsible for reporting events that
w o ~ l l daffect my annuity. Failure to report any of the events that may affect my annuity,
may result in a penalty deduction from my annuity, criminal and/or civil prosecution.
I agree to immediately notify the RRB, if
I remarry.
My marriage to the err~ployeeends in death or divorce.
I receive a lump-sum payment or begin to receive a monthly pension 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 security benefits on any person's account.
Benefits I receive directly from the Social Security Administration are adjusted for a
reason other than normal cost-of-living increases.
I go to work for a railroad or railroad labor organization or work in any capacity in
the railroad industry.
I am flling in advance and my last date of employment changes.
I return to work for
I earn over the annual earnings exempt amount.
My expected earnings amount changes.
I receive a settlement with credit for railroad service as "pay-for-time-lost" for
months after (print date railroad emplovment ended).
I perform work, including self-employment, for a family owned,controlled or
managed business, including a business operated, managed or owned by me, a
family member, friend or close associate whether for pay or not and without regard
to how the business is organized (e.g., sole proprietorship, partnership, corporation,
LLC, etc.).
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.
I receive anything of value in lieu of salary or wages for any work that I performed.
RRB Form AA3cert (xx-06)

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

Page 6

Form Approved
OMB 3220-0042

United States of America
Railroad Retirement Board

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 due to a
conviction for a crirr~inaloffense.

Signature

(First Name, Middle Initial, Last Name)

Date (MonthlDayNear)

If this certification is signed by mark ("X"), two'witnesses who know the person signing must sign below, giving their
full addresses and daytime telephone numbers.

Signature o f Witness

Signature o f Witness

Address (Street, City, State and ZIP Code)

Address(Street, City, State and ZIP Code)

-(
)
Daytime Telephone N u m b e r

()
Daytime Telephone Number

RRB Form AA-3cert (xx-06)

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

Page 7