AA1cert (proposed)(completed)

Form Approved
OMB 3220-0002

United States of America
Railroad Retirement Board

APPLICATION SUMMARY and CERTIFICATION
RRB Claim Number
Name
Social Security Number

A 813-1 1-1920
Lance Carter
813-1 1-1920

The following information was either supplied by or verified by you in support of your
application for an Employee Annuity 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.
Military Service
I was in active military service after September 7, 1939.
Recent Employment
I did not work for an employer outside the railroad industry in the last 6 months or since
leaving the railroad industry.
Railroad Employment
You have a current connection with .the railroad industry.

I have worked for the following railroad or other employer in the railroad industry.
Date Last Worked
Date Riahts Relinquished
Railroad Name
Union Pacific Railroad
08/24/2005
0812412005
Name and Address

Lance Carter
215 Backstreet Market
Marathon FI 02202

Date of Birth
Daytime Telephone Number
Type of Application Filed Employee Annuity

I am applying for a benefit based on my age and railroad service
You have requested that any payment due you be sent to the following bank account:
Bank Name
Citibank
Routing Number
213111920
Account Number
1855202152220
RRB Form AA-I cert (xx-06)

32948 64790 22000 06051 32704

Page 1

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0002

Account Type

Savings

Marriages
I am currently married.
Farmily
I do not have unmarried qualifying children.
Other Government Benefits
I am currently receiving a social security benefit.

I have not filed nor do I plan to file the next three months for Social Security benefits on an
additional account number.
In the past month I have not filed nor do I plan to file in the next three months for Railroad
Retirement benefits on any other account number.

I am not receiving nor do I expect to receive a pension or lump-sum payment based on
my earnings after 1956 for an employer not covered by Social Security or Railroad
Retirement.
Other Benefits
I expect to receive a railroad pension .from Union Pacific Railroad.
Miscellaneous lnformation
The RRB has not been furnished with a court order to enforce my child support or alimony
obligation.
The RRB has not been furnished with a court order to pay part of my present or future
railroad retirement benefit to a spouse or former spouse as part of a property settlement in
a divorce or legal separation proceeding.
I have not received nor do I expect to receive pay for time lost from my last railroad
employer.

I have not received nor do I expect to receive sick pay, under a wage continuation plan
established through company policy or a labor agreement, for a period after the actual
date I last worked.
Earnings lnformation
In 2005, you expect your total earnings will be less than $12.000.

RRB Form AA-lcert (xx-06)

32948 64790 22000 06051 32704

Page 2

Form Approved
OMB 3220-0002

United States of America
Railroad Retirement Board

Criminal Offense Information
Within the past 12 months I have not been imprisoned or been given a sentence of
confinement due to a conviction for a criminal offense.
Begir~rringDates and Filing Dates
You requested your annuity begin on the earliest date permitted by law, even if you will
receive a reduced annuity.
This application will protect your filing date for Social Security benefits.
Application for Employee Annuity - Certification
RR Claim Number
Name
Social Security Number

A 813-1 1-1920
Lance Carter
813-1 1-1920

I certify that the inforniation 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 ,fraudulentstatement 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
received, and have made and initialed any corrections on the Summary being returned to
the RRB.
I have received and reviewed the booklets RB-1 Age and Senlice Employee Annuity, RB9 Employee and Spouse Annuities - Events that Must be Reported and form G-77a How
Work Affects Your Railroad Retirement Benefits. I understand that I arrl responsible for
reporting events that would affect my annuity. Failure to report any of the events that may
affect my annuity, may result in a penalty deduction from my annuity, criminal andlor civil
prosecution.
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;
I begin to receive a pension based on earnings that are not covered by the Social
Security Administration or Railroad Retirement Board;
I file for social security benefits on any person's account;
Benefits I receive directly from the Social Sec~.~rity
Administration are adjusted for a
reason other than normal cost-of-living increases;
RRB Form AA-Icert (m-06)

32948 64790 22000 06051 32704

Page 3

Form Approved
OMB 3220-0002

United States of America
Railroad Retirement Board

I earn over the annual earnings exempt amount;
I perform any work, including self-employment, or volunteer at a family owned
business, operated or owned by me, a farr~ilymember, friend or close associate
whether for pay or not;
I become a corporate officer, own or operate a corporation, or perform work for any
corporation at any time, (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 perform;
I receive a settlement with credit for railroad service as "pay-for-time-lost" for
months after 8/24/2005;
My address changes even if my payments are sent to a financial institution;
My bank account changes;
I am confined to a jail, prison, penal institution, or correctional institution due to a
conviction for a criminal offense;
My spouse who is receiving a benefit dies or our marriage ends in divorce or
annulment;
A qualifying child niarries or leaves my custody or residence.

Signature (First Name, Middle Initial, Last Name)

Date (MonthlDayNear)

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

Signature of Witness

Signature of Witness

Address (Street, City, State and ZIP Code)

Address(Street, City, State and ZIP Code)

u
Daytime Telephone Number

L)

Daytime Telephone Number

,

RRB Form AA-I cert (xx-06)

.

32948 64790 22000 06051 32704

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