AA-1cert Application Summary and Certification

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United States of America
Railroad Retirement Board

Form Approved
OM0 3220-0002

APPLICATION SUMMARY and CERTIFICATION

RRB Claim Number
Name
Social Security Number

The following information was either supplied by or verified by you in support of your
application for an (Application Type) under the Railroad Retirement Act. After you have
reviewed the information, make any changes on the summary, initial the changeand sign
the certification on the last page. Return the certification and all pages of the summary to
the RRB.
Military Service
1 Iwas not in active military service after September 7, 1939.

1 was in active military service after September 7, 1939.

2

Recent Employment
3 1 did not work for an employer outside the raiiroad industry in the last 12 months or
since leaving the railroad industry.
4-

1 worked for the following employers outside the railroad industry in the last 12
months or since leaving the railroad industry.
(Company Name)
(Company Name)
(Company Name)

5

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

1 was self-employed during the last 12 months.

Railroad Employment
6 - You have a current connection with the railroad industry.

7

A current connection with the railroad industry is "deemed" because you:
1

2
3

Had at least 25 years of railroad service, and
"Involuntarily and without fault" stopped working for the railroad on or after
October 1, 1975 and was never called back to work for the railroad employer,
,
and
Did not decline an offer from a railroad employer to return to a job in the same
RRB Form AA-lcert (07-02)

32948 64790 22000 06051 32704

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Form Approved
OMB 3220-0002

United States of America
Railroad Retirement Board

"class or craft" as the last railroad job.
8

You do not have a current connection with the railroad industry.

9

1 have worked for the following railroad or other employer in the railroad industry.
Railroad Name
Date Last Worked
Date Relinquished Rights

Name and Address
Date of Birth
Daytime Telephone Number
Type of Application Filed
10 1 am applying for a benefit based on my age and railroad service

11 I am applying for a benefit based on being disabled.
12 You have requested that any payment due you be sent to the following bank
account:
Bank Name
Routing Number
Account Number
Account Type

13 You have requested that any payment due you be sent to the address shown above.
~a rriag'es
14

1 have never been married.

15

1 am currently married.

16

1 was previously married.

Family
17 1 have a child or children who are unmarried and under age 18.
RRB Form AA-1 cert (07-02)

32948 64790 22000 06051 32704

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Form Approved
OMB 3220-0002

United States of America
Railroad Retirement Board

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18 1 have a child or children who are unmarried and age 18 through 19 and attending
elementary or secondary school full-time.
19 1 have a child or children who are unmarried and age 18 or older with a disability that
began before age 22.
20 1 do not have unmarried qualifying children.

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Other Government Benefits
21

1 have filed or plan to file in the next three months for Social Security benefits on my
own account.

22

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

23

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

24

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

25

1 am currently receiving a social security benefit.

26

1 am not receiving a social security benefit.

27

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

28

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.

29

1 am currently receiving a railroad retirement annuity on another account number.

30

t am receiving or expect to receive a pension or I received a lump-sum payment
instead of a monthly pension based on my earnings after 1956 from an employer not
RRB Form AA-1 cert (07-02)

32948 64790 22000 06051 32704

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United States of America
Railroad Retirement Board

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Form Approved
OMB 3220-0002

covered by Social Security or Railroad Retirement.
31

1 an7 not receiving nor do Iexpect to receive a pension or lump-sum payment based
on my earnings after 1956 from an employer not covered by Social Security or
Railroad Retirement.

0th:erBenefits
32 1 am receiving a railroad pension from

,

33

1 am not receiving and do not expect to receive a pension from a current or former
railroad employer.

34

1 have received or expect to receive workers compensation benefits.

35

1 have not and do not expect to receive workers compensation benefits.

36

1 have received or expect to receive disability benefits under a Federal, state or local
government plan or law.

37

1 have not and do not expect to receive disability benefits under a Federal, state or
local government plan or law.

Miscellaneous Information
38 The RRB has not been furnished with a court order to enforce my child support or
alimony obligation.
39

The RRB has been furnished with a court order to enforce my child support or
alimony obligation.

40 - 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.
41

The RRB has been furnished with a court order to pay part of my present or future
railrdsd retirement benefit to a spouse or former spouse as part of a property
settlement in a divorce or legal separation proceeding.

42

1 have not received nor do I expect to receive pay for time lost from my last railroad
employer.

43

1 have received or expect to receive pay for time lost from my last railroad employer.
RRB Form AA-1 cert (07-02)

32948 64790 22000 06051 32704

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Form Approved
OMB 3220-0002

United States of America
Railroad Retirement Board
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44

1 have not received nor do I expect to receive sick pay, under a wage continuation
plan established through company policy or a labor agreement, fora period after the
actual date I last worked.

45

1 have received or I expect to receive sick pay, under a wage continuation plan
establkhed through company policy or a labor agreement, for a period after the
actual date I last worked.

Earnings Information
46 Last year your total earnings were $999,999.99
47

Last year your earnings were less than $999,999.99

48

Last year you earned more than $9999 in each month.

49

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

50 This year you expect your total earnings will be $999,999.99.
51

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

52

This year you expect to earn more than $9999 in each month.
This year you expect to earn less than $9999 in the following months:
January February March April May June. July August September October
November Decerr~ber

53

54
55

Next year you expect your total ea-rningswill be $999,999.99.
,

Next year your total earnings will be less than $999,999.00.

Felony Information

56 Within the past 12 months I have not been imprisoned or been given a sentence of
confinement for conviction of a felony.
57

Within the past 12 months I have been imprisoned or been given a sentence of
confinement for conviction of a felony.
RRB Form AA-lcert (07-02)

32948 64790 22000 06051 32704

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Form Approved
OMB 3220-0002

United States of ~rnerica
Railroad Retirement Board

Begir~ningDates and Filing Dates
58

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

59

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

60 You have selected mmlddlyyyy for the beginning date of your annuity.
61

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

62

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

Medicare
63

You are enrolled in the Medicare Medical lnsurance Plan (Part B).

64

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

65 You do not wish to enroll in the Medicare Medical Insurance Plan (Part 6)at this
time.
66

My annuity will begin before I am age 63 and I am totally disabled for work.

67

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

68 You are claiming premium surcharge relief based on coverage by an employer group
health plan.

Application for (Application Type - Certification)

RR Claim Number
Name
RRB Form AA-I cert (07-02)

32948 64790 22000 06051 32704

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Fonii Approved
OMB 3220-0002

United States of America
Railroad Retirement Board

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

Printed if application is for Employee Annuity
I have received and reviewed the booklets RB-I Age and Service Annuity and RB-9
Employee and Spouse Annuities - Events that Must be Reported. I understand that I am
responsible for reporting events that w o ~ ~affect
l d my annuity.
Printed if application is for Disabled Employee Annuity
I have received and reviewed the booklets RB-I Age and Service Annuity, RB-Id
Employee Disability Benefits and RBL9 Employee and Spouse Annuities - Events that
Must be Reported. l understand that l am responsible for reporting events that would
affect my annuity.

I agree to immediately notify the RRB, if
I go to work for any employer in the railroad industry;
I begin to receive a pension based on earnings that are not covered by the Social
Security Administration;
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 am filing in advance and my last date of employment changes;
I return to work for (show last non railroad employer).
I earn over the annual earnings exempt amount.
My expected earnings amount changes.
I begin to receive worker's compensation or public disability benefits.
Ibegin to receive a pension or lump-sum payment from my railroad employerMy address changes;
My bank account changes;
I am confined to a jail, prison, penal institution or correctional institution for
conviction of a criminal offense.
RRB Form AA-lcert (07-02)

32948 64790 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0002

Signature (First Name, Middle Initial, Last Name)

Date

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

Signature of Witness

Signature o f Witness

Address (Street, City, State and ZIP Code)

Address(Street, City, State and ZIP Code)

u

u
Daytime ~ e l e ~ h o n
Number
e

Daytime Telephone Number

RRB Form AA-lcert (07-02)

32948 84790 22000 06051 32704

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