AA-1 Application for Employee Annuity

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

r

Do Not Write In This Space
MONTH

DAY

YEAR

OFFICE NUMBER

INEXTITO

APPLICATION FOR

-y
R;

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APPROVED

EMPLOYEE ANNUITY

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DATE
. - CODED
- - - --

MONTH

APPLICATION NUMBER

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YEAR

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General Instructions
Before you complete this application, be sure to read the booklet RB-I, Age and Service Employee Annuity, which explains
information you will need to answer many of the questions in this application. Also be sure to read the important notices in the
the RB-I booklet.
Type or print legibly in ink. If you need more space than is provided to answer a question, use Section 21 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

016 016 2 0 1 0 1 7
Some items in this application will not apply to you and 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 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.

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

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Identifying Information
Check the information entered by the Railroad Retirement Board (RRB) for Items 1 through 5 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
ldentifjcation 1

SOCIAL SECURITY NUMBER

3

EMPLOYEE'S NAME

>

-

4 a MAILING ADDRESS

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151

CITY AND STATE

1 1 I ZIPCODE

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2

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RAILROAD RETIREMENT CLAIM NUMBER

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>

DAYTIME TELEPHONE NUMBER

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Form AA-1 (XX-XX) Destroy Prior Editions

Information About You and Your Family
6

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

7

Enter your name at birth if different from ltem 3.

Marital
Status

Marriage

*

Enter an " X in the box that shows your
current marital status.

Enter your spouse's full name before your marriage.

11

Enter your spouse's date of birth.

Go to Item 16
Go to ltem 10
Go to Item 14

--+
Month

+

Enter your spouse's social security number.
If none, enter "To Be Submitted."

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Day

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*

12 Enter the date of your marriage.

Previous
Marriage
History

m Never Married
m Married or Separated
m Other

*

10

13

m Male
m Female

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Month

Day

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Year
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Year

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+

Enter an "X" in the appropriate box:
I was previously married. (Answer "No" if your only
previous marriage was an earlier marriage to your
current spouse.)

1

m Yes + Go to ltem 15
m No + Go to Item 16

-

4

Give the following information for your previous marriage(s). Use Section 21 if you have more than one previous
marriage.

a

(i)MARRIAGE BEGAN
DATE

CITY & STATE

(ii) NAME OF FORMER
SPOUSE

(iii) MARRIAGE ENDED

a

m
m
(iv) Enter your former spouse's date of birth.

CITY & STATE

DATE

REASON

m

DEATH
DIVORCE
ANNULMENT
OTHER - Explain in
Section 21

Month

-*

-

(v) Enter the Social Security Number of former spouse
shown in Section 15a(ii).

Day

Year

If unknown, enter unknown and complete ltem 15b.

Enter your former spouse's
Place of birth P

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Children

Father's name

Mother's maiden name

Please read Part I of the RB-1 booklet for an explanation of family members who could qualify you for the
Special Guaranty Computation.

I Enter an " X in the appropriate box:

m Yes + Go to Note and ltem 17
m No + Go to ltem 18

I have children who are unmarried and meet any of the
-+
following conditions:
(1) Under age 18.
(2) Age 18 through 19 and attending elementary or
secondary school full-time.
(3) Age 18 or older with a continuing disability that began
before age 22 and prevents any kind of employment.

Note: I f you have a child that meets the disability requirements, also complete Form AA-19a,
Application for Determination o f Child's Disability.

Enter in each box the number
of children who meet each condition.

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Form AA-1 (XX-XX) Page 2

m
m
m

w

,

Under age 18.
Age 18 through 19 and attending elementary
or secondary school full-time.
Age 18 or older with a continuing disability
that began before age 22 and prevents any
kind of employment.
I

Do not complete ltem 18 if you have never married; go to ltem 19.
Garnishment 18
or
Property
Settlement

Enter an "X" in the appropriate box:
a. The RRB has been furnished with an order to enforce either
my child support or alimony obligation, or to pay part of my
present or future railroad retirement benefit to a spouse or
former spouse as a part of a property settlement in a divorce
or legal separation proceeding. (NOTE: Reference to
pension rights may be found in the property settlement.) +
b. Which situation applies?

Criminal
Offense

+

m Child Support or Alimony

e

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-- 1

20
21

Enter the date of the sentence of confinement.

22

1 1
24

Month

+

Enter the date of the conviction.

Enter the date that confinement began.

*

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

*

Enter the date confinement ended.

*

Property Settlement

m Yes
m No

Enter an "X" in the appropriate box:
Within the oast 12 months. I have been imorisoned or niven a
sentence of confinement due to a conviction for a criminal
offense.

19

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m Yes + Go to ltem 18b
m No Go to Item 19

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+ Go to ltem 20
+ Go to Section 4
Day

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Month

Year

Day

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Month

Day

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Year

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Year

m Yes
m No
Month
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+ Go to ltem 24
+ Go to Section 4
I Day I
Year

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lnformation About Type of Annuity
Please read Part I of the RB-I booklet for information about age and service annuities. Also read the RB-Id booklet if you are
applying for a disability annuity.
Type of
Annuity

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1 25 1

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

*

Enter an "X" in the appropriate box:
I am eligible for and will accept a reduced age annuity
if I am not eligible for a full age or a disability annuity.
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a
a
a
a

-

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FULL AGE ANNUITY
FULL 60130 AGE ANNUITY
DISABILITY ANNUITY

}

$
2
6::

REDUCED AGE ANNUITY- LESS
THAN 30 YRS' SERVICE

Section 5

m Yes
m

lnformation About Military Service
Please read Part I of the RB-I booklet for information about mfiitary service. Creditable military service is used to determine, in
part, your annuity eligibility. It can also be used in your annuity computation.
Military
Service

-

27

Enter an "X" in the appropriate box:
I was in active military service, such as the Army, Navy,
Air Force or Marines, of the United States.

m Yes
m No

+ Go to

1

Note and Item 28

+ Go to Section 6

Note: If answered "Yes, "you must submit proof of your military service, such as your discharge
certificate or separation papers, as explained in the RB-I booklet.
Enter an "X" in the appropriate box:
I had voluntary military service during the period June 15,
1948, through December 15, 1950.

*

-

Enter an "X" in the appropriate box:
I had nonrailroad earnings after leaving the military service
stated in ltem 28 and before returning to the railroad.
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m Yes
m No
m Yes
m

+ Go to Item 29

+ Go to ltem 30

Form AA-1 (XX-XX) Page 3

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Military
Service
Monthly
Benefits

Enter an 'X' in the appropriate box:
I have filed, or plan to file, a claim for monthly benefits with another
federal agency based on military service perfonned before
January I,1957. (Answer "No" if the other federal agency is the
Department of Veterans Affairs, the Social Security Administration,
or the Railroad Retirement Board.)
Enter the name of the other federal agency.

-*

a Yes +
a No +

-

Enter the date you filed a claim with the agency named in Item 31 Month
and go to ltem 33. If you have not already filed a claim with that
agency, enter the date you plan to file and go to Section 6. -+

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Enter the claim number of the monthly benefit you have
already filed for.

*

Go to ltem 31
Go to Section 6

Year

Day

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Information About Your Railroad Work
Please read Part I of the RB-I booklet to find out what railroad work is creditable. Creditable railroad work is used to
determine your annuity eligibility and is also used in the annuitv computation.
Railroad

Enter an "X" in the appropriate box:
I have less than 360 months of railroad work
after 1936.

Work Before
1937

*

-

Enter an " X in the appropriate box:
I worked in the railroad industry before 1937.

a
a
a
a

Yes

+ Go to ltem 35

No

+ Go to ltem 36

Yes

+ Go to Note and ltem 36

No

+ Go to ltem 36

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Last Railroad 36
Employment
37

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Note: To obtain credit for your railroad senlice before 1937, complete and refum to the RRB, Form AA-15,
Employee's Statement of Service Performed Before January 1, 1937, to Employers Under the
Railroad Retirement Act.

Enter the name of the railroad company or railroad
labor organization that last employed you.

I
-

Enter your payroll name and identification number for
that employer.

1 38 1

Enter your last job title for that employer.

1 39 1

Enter your last division or department and its location.
Enter the dates you worked for that employer.
(If your railroad employment has not ended,
enter the last date you will work for that
employer in the " T O date.)

*

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FROM
Month Day

+

Enter the date you gave up or will give up your seniority
Month
rights and all other rights to work for the employer shown
in ltem 36. (Make no entry if you have not given up your
rights because you are filing for a disability annuity.) +
Other
42
Railroad
Employment

43

Enter the name of that employer.

*

44

Enter your payroll name and identification number for
that employer.

*

45

Enter your last job title for that employer.

Year

Day

I
1
a Yes +
a No

Enter an "X" in the appropriate box:
I worked for another employer in the railroad industry
or a railroad labor organization this year or last year. --t

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Form AA-1 (XX-XX) Page 4

TO
Month Day

Year

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Go to Item 43

+ Go to Item 49

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Year

Other

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

Employment

*
FROM
.Month Day

-

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

Enter the date you gave up or will give up your seniority rights
and all other rights to work for the employer shown in ltem 43.
(Make no entry if you have not given up your rights because
you are filing for a disability annuity.)

Month

Day

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*

Railroad
Seniority
Rights

49

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Enter an " X in the appropriate box:
I still have seniority or other rights to work for a
railroad employer or railroad labor organization
not listed in Item 36 or Item 43.

*

Print the name of any employer indicated
in ltem 49 with whom you still have rights
to return to work.

+

CI Yes
CI No

TO
Month Day

Year

Year

Year

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+ Go to ltem 50
+ Go to Section 7

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lnformation About Pay For Time Lost
Please read Part II of the RB-I booklet to find out what payments can be creditable as pay for time lost.
Pay For
Time Lost

51

Enter an "X in the appropriate box:
I received or expect to receive pay for
time lost from my last railroad employer.

-

0 Yes + Go to Note and ltem 52
+

Go

Note: I f answered "Yes," and you received an injury settlement or elected to receive "dismissal pay,"
enclose a copy of your settlement or election with your application. I f your case is still pending, briefly
explain i t in Section 21.

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52

1 FROM

Enter the dates for which
these ~ a ~ m e nwere
t s made or
will be'mede.

I TO

Month1 Day
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Year

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IMonthl Day
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Year

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Year

lnformation About Railroad Sick Pay
Please read Part II of the RB-I booklet to find out when sick payments can be creditable to Tier I.
Enter an " X in the appropriate box:
I received or expect to receive sick pay
under a railroad wage continuation plan
(other than my own regular salary) that
was established through a company policy
or labor agreement and this pay was for a
period after the actual day I last worked.
(Answer "No" if you were carried on the
payroll and just received your regular
salary.)

Enter the name of the sick pay plan, if known.
I

CI Yes
CI No

+ Go to ltem 54a
+ Go to Section 9

*

-

--

b

Enter the dates for which these payments were made or will be made for
up to 6 months after your actual day
last worked.

FROM
Month1 Day

I

Year

TO
~ o n t h lDay

w

Form AA-1 (XX-XX) Page 5

Please read Part IV of the R B - I booklet, which explains how Last Pre-Retirement Nonrailroad Employment, self-employment,
and other earnings affect your annuity. Also read Part I of the booklet which explains "Current Connection."
Nonrailroad

55

Work

1

Enter an 'X. in the appropriate box:
I worked for pay outside the railroad industry
either during the last 6 months I worked in the
railroad industry or after I left the railroad industry.
(Do not include self-employment. Include any
employment for an incorporated business which
you own or public service. If you are a Canadian
citizen or permanent resident, include employment
in Canada for the U.S. railroad employer performed
January 1, 1983, or later.)

-

Yes

-t

Go to Note and ltem 56

No

+ Go to ltem 66

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f

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~ o t e If: you had Last Pre-Retirement Nonrailroad Employment (LPE) after your annuity would begin.
complete Form G-19F, Earnings Information Request, only when one of the following applies:
(I)
The annuity beginning date (ABD) is before January I 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.
l
Most Recent 56
Nonrailroad
Work

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57

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

*

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

*

/

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

59

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Enter the name and address of your next most
recent nonrailroad employer during your last 6
months in the railroad industry or after you left
the railroad industry.

Recent
Nonrailroad
Work

I

Enter an "X" in the appropriate box:
The employer named in ltem 56 is either a seasonal
employer or a Federal Government agency that is
listed in Chapter 5 of the RB-1 booklet.

1 1
62

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63

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FROM
~ o n t h lDay
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+

(

Year

l ~ o n t h lDay
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II

Year

I am still working

Q Yes

*
If none, enter "NONE" and go to ltem 66

+

Enter your last job title for that employer. ------,
Enter your average monthly salary for that employer.
(SHOW DOLLARS ONLY)

1 TO

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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.")
Enter an " X in the appropriate box:
The employer named in ltem 61 is either a seasonal
employer or a Federal Government agency that is
listed in Chapter 5 of the R B - I booklet.
A
Form AA-1 (XX- :X) Page 6

FROM
Month Day

*

I am still working

Q Yes
w

Year

TO
Month Day

Year

If you are employed and your business is incorporated, answer ltem 66 "No." Make sure Items 55-65 are also
completed. If your business is not incorporated, answer ltem 66 "Yes" and go to Item 67.
66

I I

Enter an "X" in the appropriate box:
I was self-employed during my last
6 months in the railroad industry or
after I left the railroad industry.

Q Yes + Go to Note and Item 67
No

+ Go to Section 10

Note: I f answered 'Yes,"complefe and refurn fo fhe RRB, Form AA-4, Self-Employment and
Substantial Service Questionnaire.

1

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Enter an " X in the appropriate box:
I am still self-employed.

Enter the date you were last self-employed.

*

Q Yes

+ Go to Section 10

Q No + Go to Item 68

-1 1 1
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;D

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II

YEAR
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Deemed Current Connection

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Please read Part I of the RB-I booklet for an explanation of a deemed current connection.
Deemed
Current
Connection

69

Enter an "Xu in the appropriate box:
I have at least 25 years of railroad service
and I have indicated nonrailroad employment
in Items 55-68 that could break my current
connection.

I I
70

Enter an " X in the appropriate box:
I was separated from my last railroad
employer involuntarily and through no fault
of my own on or after October 1, 1975.

Q Yes
Q No

+ Go to ltem 70
+ Go to Section II

w

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Q Yes + Go to ltem 72

0 No + Go to Item 71

+
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71

Enter an " X in the appropriate box:
I was on furlough, leave of absence or
absent because of injury status with my
last railroad employer on October 1, 1975,
and was never called back to work.

72

Enter an " X in the appropriate box:
I declined an offer to work in the railroad
industry in the same "class or craft" as my
last railroad job.

a

Yes

+ Go to ltem 72

Q No

+ Go to Section II

a

+ Go to Section 11

>

Yes

Cjl No + Go to Note and Section I 1

*
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ote: I f you answered either lfem 70 or lfem 71 "Yes" and lfem 72 "No," submif fhe required proofs a
soon as possible. This will preserve your righfs under fhe deemed currenf connecfion provisions. The
required proofs are explained in fhe RB-I booklef.
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Information About When Your Annuity Will Begin

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Please read Part II of the RB-I booklet for an explanation of an annuity beginning date.
Annuity
Beginning
Date

73

74

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

Cjl Yes + Go to Section 12

+

--

No
Month

+ Go to ltem 74
Day

Year

Form AA-1 (XX-XX) Page 7

Information About Your Earnings
Before answering Items 75-87, please read Part IV of the RB-7 booklet to find out how earnings can affect an age
and service annuity. For the exempt amounts, refer to Form G-77a, How Work Affects Your Railroad
Retirement Benefits.
If you are applying for a disability annuity but are eligible for and would accept a reduced age annuity if the disability
annuity is denied, answer ltems 75-87, which apply to the reduced age annuity. Otherwise, go to Section 13.
Earnings
Last Year

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

(Year)

u Yes
u No

*

Enter an " X in the appropriate box:
My total earnings from all employment last year were
more than the annual earnings exempt amount. (If all your
earnings are from only railroad employment before your
date last worked, answer "No.")

I

u Yes
u No

*

+ Go to ltem 76

+ Go to ltem 80

+ Go to ltem 77
+ Go to ltem 80

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

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

-

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 in self-employment.

Earnings
This Year

+ Go to ltem 80

+ Go to ltem 79

*

Enter an " X in the appropriate box:
I expect my total earnings from all employment this year to
be more than the annual earnings exempt amount. (If all
your earnings are from only railroad employment before
+
your date last worked, answer "No.")
81

u Yes
u No

Yes

+ Go to ltem 81

No

+ Go to ltem 84

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

Enter an " X in the appropriate box:
I expect to earn more than the monthly earnings exempt
amount in employment for hire, or to perform substantial
services in self-employment in every month this year. -+

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Earnings
Next Year

I

1

1

u Yes
u No
u Yes
u NO

--

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

85

u Yes
u No

+ Go to item 84
+ Go to Item 83

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

Enter an " X in the appropriate box:
I am filing this application in September, October,
November, or December.

(Year)

1
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1

Form AA-1 (XX-XX) Page 8

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+ Go to ltem 85

+ Go to Section 13
+ Go to Item 86
+

GO

Section 13

Earnings
Next Year
(Cont.)

86

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

.
$

Enter an "X" next to each of the first four
months of next year in which you expect to
earn less than this year's monthly earnings
exempt amount.

>

lnformation About Social Security Benefits
Please read Part V of the RB-1 booklet to see how this application can protect your rights to social security benefits, and
to see what effect your receipt of 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.)

Q Yes

u No
*

u Yes + Go to ltem 90
u No + Go to Section 14

.

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.

Month

Enter the date you became, or will become, eligible
for these sociai 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).

*

I
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Year

I

u Yes + Go to ltem 92
u No + Go to ltem 93

-

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 myself.

u Yes + Go to ltem 94
u No + Go to Section 14

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

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-

a

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lnformation About Non-Covered Service Pension
Please read Part V of the RB-1 booklet for information concerning non-covered service pensions. Complete Items 96 and 97
only if your date of birth is January 2, 1924, or later. Otherwise, go to Section 15.
Non-Covered
Service
Pension

Enter an " X in the appropriate box:
I am receiving or expect to receive a pension or annuity
or lump sum in excess of contributions based on any
work after 1956 not covered by social security or
railroad retirement.

u Yes + Go to Note and Section 15
* u No + Go to Section 15
I1 II \{ Note:
I f answered "Yes," complete Form G-209, Emp;oyee Non-Covered Service Pension
\
Questionnaire.
97

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*

u Yes + Go to ltem 97
u No + Go to Section 15

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Enter an " X in the appropriate box:
The beginning date of the pension or
annuity is January 1, 1986, or later.

I

Form AA-1 (XX-XX) Page

lnformation About Other Railroad Retirement Annuity

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Please read Part V of the RB-1 booklet for an explanation of the effect of your employee annuity on any other railroad
retirement annuity.
Other
Railroad
Annuity

98

-

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99

1

1

-

Enter an " X in the appropriate box:
I have filed within the last 30 days, or intend to file
within the next 90 days, for an annuity based on
another person's railroad earnings record.

n Yes + Go to Item 99
n No + Go to Section 16

*

Enter the full name of that other person.

If only six numbers, enter here

Prefix

100 Enter that other person's Railroad
Retirement Board claim number, including
the letter prefix.

1

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lnformation About Supplemental Annuity

I

Please read Part I of the RB-1 booklet for an explanation of what is required to be eligible for a supplemental annuity.

!

Supplemental 101 Enter an " X in the appropriate box:
Annuity
I am now, or will be, eligible for a supplemental annuity
Eligibility
from the Railroad Retirement Board (before reduction
>
for a company pension).

n Yes + Go to ltem 102
n No + Go to Section 17

102 Enter an "X" in the appropriate box:
I am receiving, or expect to receive, a monthly
pension or lump-sum pension payment from one
or more former railroad employers.

n Yes + Go to ltem 103
n No + Go to Section 17

I I

103 Enter the name of the last railroad employer
with whom you still hold pension rights.

104 Enter an "X" in the box which most accurately
applies to the job or position which qualified
you for this pension.

*
>

n Salaried
n Non-Agreement
n Agreement
n Other

*

1
1
1
Mo;th

105 Enter the date your pension began, or will begin, or
the date of your lump-sum pension payment.

;D

Y;ar

106 Enter the name of the second to last railroad employer
with whom you still hold pension rights. (If this
employer is now part of the employer in ltem 103,
leave this item blank and go to ltem 109.)
107 Enter an " X in the box which most accurately
applies to the job or position which qualified
you for this pension.

Enter the date your second pension
began, or will begin, or the date of your
lump-sum pension payment.
Enter an " X in the appropriate box:
The pension named in Item 103 or Item 106
is based on a collective bargaining (union)
agreement.
I

I

I

Form AA-1 (XX-XX) Page 10

n Salaried
n Non-Agreement
n Agreement
n Other

*

Month

*

n Yes
n

+
I

Day

Year

1

I

-1

Information About Medicare
Complete this section only if you are 64 years and 5 months of age or older.
Please read Part VI of the RB-I booklet for an explanation of the Medicare program.
Medicare
Enrollment

110 Enter an "X" in the appropriate box:
I have a Medicare card that shows entitlement
to Medicare medical insurance (Part B).

m Yes + Goto Item 111
m No + Go to ltem 112

*

111 Enter your Medicare claim number.
>
(If this is a railroad retirement filing, enter the prefix. If this
is a social security filing, enter the suffix).
112 Enter an "X" in the appropriate box:
I have filed for Part B within the last
*
three months.

Go to Section 18

m Yes + Go to Item 113
m No + Go to ltem 114

113 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
this is a social security filing, enter the suffix.)
Date of filing

Month

/

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

Go to Section 18

m

*

m
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 em~lovment.

Yes + If you are under age 65 years
and 4 months, go to Section 18.
If you are older than age 65 years and 3
months, go to ltem 115.
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 18.

m yes + Goto ltem 117
m No + Gotoltem116

-

\

-

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

Yes

I

-

If applicable, the date employment will stop for the
person whose employment qualifies me for EGHP
coverage is:

b. I am requesting a Part B effective date of
121 Enter an "X" in the appropriate box:
I am requesting premium surcharge relief
for the months of EGHP coverage.

Section l8

Day

I

Year
I

,

Year
Month Day
-

Month

118 The beginning and ending
dates of my EGHP cover- / EGHP Beginning Date ---,
age and the date last
!
worked in the employment EGHP Ending Date
which qualified me for
!
EGHP coverage are:
; Date Employment Stopped -+

-1

120 Enter an "X" in the appropriate box:
a. 1 am enrolling in Part B while either still covered by
an EGHP or during the first full month after my
EGHP coverage.

+ Go to Item 118
+

Month

117 The beginning date of my EGHP coverage is:

Enter an "X" in the appropriate box:
I wish to enroll in a special enrollment period.

Year

Day

1

>

w

Go to Item 119
Day

Year

Go to Item 119

m Yes + G o t o l t e m 1 2 0
0 No

+ Go to ltem 121

m Yes + Go to ltem 120b
m No + Go to Section 18
Month

Day

m Yes

Year

Go to
Section 18

El No
Form AA-1 (XX-XX) Page 1 1

Disability Medicare
If you are filiug for a disability annuity, go to Section 19.
If you are less than 64 years and 5 months of age, and you are not filing for a disability annuity, you may be entitled to
Medicare benefits based on your being totally disabled for all employment and being entitled to an annuity before age 63.
If your entitlement begins affer age 63, you may not be entitled to early Medicare, but you may be entitled to have your Tier I
benefit treated as a social security benefit for taxation purposes. See Form TB-85, lnformation About the Taxation of
Railroad Retirement Annuities, Part 6, Section 6A.
122 Enter an " X in the appropriate box:
I expect my annuity to begin before I
reach age 63.

Medicare

123 Enter an " X in the appropriate box:
I am totally disabled for work in all
regular employment.

*

0 Yes

+ Go to ltem 123

m No

+ Go to Section 19

m Yes
*

0 No

+ Go to Note and Section 19
+ Go to Section 19

I

Note: If answered "Yes," complete and return Form AA-Id, Application for Determination
of Employee's Disability, to apply for Medicare based on disability.
I

I

lnformation About You If You Are Disabled
Answer Items 124-126 ONLY if you are applying for a disability annuity. Otherwise, go to Section 20. If you are applying
for a disability annuity, also complete and return Form AA-Id, Application for Determination of Employee's Disability.
You are asked about your children to determine if you are entitled to a special annuity computation.
Please read Part V of the RB-I booklet for an explanation of worker's compensation benefits and public disability benefits.
Child Living
With You

124 Enter an "X in the appropriate box:
After 1950 1 had living with me at least
one of my own or my spouse's children,
who was under age 3.

0 Yes

m No

-

/

Worker's
125 Enter an " X in the appropriate box:
Compensation
Since my disability began, I have

received, or expect to receive,
worker's compensation benefits.

m Yes + Go to Note and ltem 126
m No + Go to Item 126

w
I

Note: If answered "Yes,"proof of the amount(s) and effective date(s) of your worker's
compensation benefit is required.

Public
Disability
Benefits

126 Enter an " X in the appropriate box:
Since my disability began, I have
received, or expect to receive, disability
benefits under a Federal, state, or local
government plan or law.
(Answer "No" if your benefits are social
security, veterans affairs, or welfare.)

0 Yes

m No

+ Go to Note and Section 20

+ Go to Section 20

w
I

Note: If answered "Yes," proof of the amount(s) and effective date(s) of your public disability
benefit is required.
I

I

I

Form AA-1 (XX-XX) Page 12

I

Please read Part VII of the RB-I 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 21, or call your financial institution for the information you need to complete Items 127-131. If you do not
have a bank account, or receiving your payments by Direct Deposit would cause you a hardship go to Item 132.
Direct
Deposit

127 Enter the name of your financial institution.

-

Area Code
128 Enter the telephone number of your
financial institution. P
-

129 Enter the routing transit number of your financial institution.

I
130 Enter your account number.
- -

4

CI Checking
CI Savings

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

~

Go to Section 21
132 Check this box if you do not have a checking
or savings account, or if Direct Deposit would
cause you a hardship.
I

I

*

CI
I

Remarks
I

Remarks

I

I

133 This section is to be used for the continuation of answers to other items. Be sure to include the item number
at the beginning of the answer you wish to continue. You may also use this section to enter any additional
information that you feel may be important to include.

I

I

Form AA-1 (XX-XX) Page 13

I

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

-

a
a

YES + Go to Note and Item 135
NO + Go to ltem 135

Note: If answered "Yes," your guardian or other represenfafive must sign this application. That
person must also complete and return Form AA-5, Application for Substitution of Payee.
I 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-I, Age
and Service Employee 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 begin to receive a pension based on earnings that
are not covered by the Social Security Administration
(SSA) or the RRB.

IF benefits I receive directly from SSA are adjusted for a
reason other than normal cost-of-living increases.
IF my address changes.

IF I begin to receive benefits directly from SSA.

IF I am confined in a jail, prison, penal institution, or correctional facility due to a conviction for a criminal offense.

IF I am disabled and begin to receive worker's
compensation or public disability benefits.

IF I earn more than the annual earnings exempt amount.

IF I am entitled to a supplemental annuity from the RRB
and receive a lump-sum pension payment or begin to
receive a monthly pension from my railroad employer.

IF 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.).

IF I am entitled to a vested dual benefit and begin to
receive a benefit based on military service performed
entirely before 1957.
IF I go to work for a railroad or railroad labor organization,
or return to work in any capacity in the railroad industry.

IF my spouse who is receiving a benefit dies, or our
marriage ends in divorce or annulment.

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

IF a qualifying child marries or leaves my custody or
residence.

IF I am filing in advance of the date(s) shown in Item(s)
40 (and 47), and there is a change in a date.

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 I receive a settlement with credit for railroad service
as "pay-for-time-lost" for months after the date(s)
shown in Item(s) 40 (and 47).

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

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 andlor civil prosecution.

SIGNATURE
(First Name, Middle Initial,
Last Name)

> =

I

,

*

DATE

Month

Day

Year

If this certification is signed b y mark ( " X ) in ltem 135, t w o witnesses w h o k n o w t h e person signing must
sign below, giving their full addresses a n d daytime telephone numbers.
3. 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
I

) Page 14

Area Code

Telephone Number

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 serving your location. 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 followiqg are enclosed:

/

\

*

needed proofs

*

the application form itself

*

additional forms you were asked to complete

Note: After the RRB receives your application, a receipt form with information about your claim
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.

\

I

Form AA-I (XX-XX) Page I!