Form AA-17B Application for Determination of Widow(ers) Disability

UNITED STATES OFAMERICA
RAILROAD RETIREMENT BOARD

FORM APPROVED

O.M.B.No. 3220-0030
DO NOT WRITE IN THIS SPACE
OFFICIALLY FILED

DAY

YEAR

OFFICE NUMBER

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APPLICATION FOR
DETERMINATION
OF WIDOW(ER)'S
DISABILITY

APPROVED

DATE CODED
MONTH

APPLICATION NUMBER

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DAY

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YEAR

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CODED BY

General Instructions
Before you complete this application, be sure to read Part I of booklet RB-17b, Widow(er)'s Disability Benefits, which explains information
you will need to answer many of the questions in this application.
Please read "Important Notices" on page 11 of this application.
Print all answers in ink or use a typewriter. If you need more space than is provided to answer a question, use Section 9 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 December 13,
1998, as:
Month

Some items in this application will not apply to you so 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 form 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.
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 6 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.

*

1 1

imployee
dentification

1

1 (
1 1
2

EMPLOYEE'S SOCIAL SECURITY NUMBER

3

EMPLOYEE'S RAILROAD RETIREMENT CLAIM NUMBER

1 1

ipplicant
dentification

EMPLOYEE'S NAME

5

a

STREET ADDRESS

b

CITYANDSTATE

c

ZIP CODE P

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6

COUNTY

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APPLICANTS NAME

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4

d

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DAYTIME TELEPHONE NUMBER

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Form AA-17b (06-04) Destroy Prior Editions

Information About Your Medical Condition

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no : ! :

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Hw
Condition
Affects
Work

Enter the date this condition began to adversely affect
your ability to work.

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Enter an "X" in the appropriate box:
I have worked since the date in ltem 8.

es

D No

-+

Go to Item 10

-+

Go to ltem 12

10 Enter an "X" in the appropriate box:
Yes
Did your condition cause you to change:
Q If "Yes" to
Your job duties? Y
any item, go
Your hours of work?
>
to Item 11
Your attendance?
Anything else about your work? I
D

No

-

11

.

12

D
D

all items, go
to Item 12

Explain what the changes in your work circumstances were, the dates they occurred, and why your condition
made these changes necessary.
Changes in Work Circumstances

When
Unable to
Work

Q If "No" to

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Dates

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Why Your Condition Made Changes Necessary

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Month

Enter the date you could no longer work because of your
condition.

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Day

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Year
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13 Describe how your condition affects you and keeps you from working.

Current
Work
Status

14 Enter an " X in the appropriate box:
My condition prevents me from working now.

-

15 Enter the date you became able to work again.

Yes

+

Go to Section 4
Go to ltem 15

Q No

,

Information About Your Medical Care
Medical
Care or
Examination

16

Treatmentor
Testing

17 Enter an " X in the appropriate box:
I have been treated or tested (inpatient or outpatient) at a
hospital, institution or clinic, including a Department of
Veterans Affairs or other government facility.

Enter an " X in the appropriate box:
I have received medical care or been examined for my
condition since the date in Item 8.

Form AA-17b (06-04)

Yes

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Page 2

Q IVo
Yes

Q No

-+

Go to ltem 17

-+

Go to Section 5

-+

Go to ltem 18

-+ Go to ltem 19

Treatment or
Testing
(Continued)

18 Enter information about each hospital, institution, or clinic where you have received treatment or care
since the date in Item 8.
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Name of Facility

Address and ZIP Code

Attending Physician's Name
Enter an " X in the appropriate box:
lnpatient
Outpatient

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Telephone Number

Area Code

Patient Number

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! Describe Type of Treatment or Testing

Dates Treated or Tested

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b Name of Facility

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Address and ZIP Code

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Attending Physician's Name

1 1 Enter an " X in the appropriate box:
lnpatient

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Outpatient

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Telephone Number

Area Code

Patient Number
Dates Treated or Tested

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! Describe Type of Treatment or Testing
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c Name of Facility

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Address and ZIP Code

Attending Physician's Name
Enter an " X in the appropriate box:
Inpatient
Outpatient
Patient Number

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Dates Treated or Tested

Area Code

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Telephone Number
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! Describe Type of Treatment or Testing
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1 Doctor
Treatment

19 Enter an 'X. in the appropriate box:
My personal physician or other doctor treated me since
the date in ltem 8.

Yes + Go to ltem 20

* CI No

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Page 3

+ Go to ltem 21
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Form AA-17b (06-04)

Doctor
Treatment
(Continued)

20 Enter information about each personal physician or other doctor who has treated you.
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Name of Physician

Address and ZIP Code

Telephone Number

Area Code

Patient Number
Dates Treated or Examined
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Describe Type of Treatment or Testing

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Name of Physician

Address and ZIP Code

Telephone Number

Area Code

Patient Number

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Dates Treated or Examined

! Describe Type of Treatment or Testing
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4ctivity
Restriction

21

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23

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a Yes

Enter an "Xn in the appropriate box:
A medical doctor restricted my daily
activities since the date in Item 8.

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C] No

--

Go to ltem 22
Go to ltem 26

Enter the name of the medical doctor
who imposed the restriction.
Enter the date the restriction began.

orm AA-17b (06-04)

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Page 4

Enter the address of the
medical doctor in ltem 22,
if it has not previously been
printed in Items 18 or 20.

Activity
Restriction
(Continued)

1 Medication

Enter an " X in the appropriate box:
lbledication has been prescribed for me.

>

D Yes

+ Go to Item 27

Q No

+

Go to Section 5

Enter the name or type of medication and the dosage from the prescription label.
Enter information for all medications prescribed for you.
NAMElTYPE:

Schooling

1

DOSAGE:(grams,number of pills.etc.)

Enter the highest grade of school you completed
and the last year you attended school.

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Enter an " X in the appropriate box:
I attended technical school.

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FREQUENCY:

es -+

Go to Item 30
Go to ltem 33

Q No

Describe the type of technical school you attended.

Enter an " X in the appropriate box:
I received a certification or license from
the technical school I attended.

Yes

Q No

>

--

+ Go to Item 32

Go to ltem 33

Enter an " X in the appropriate box:
D Yes
Go to ltem 33
The certification or license I received is
Go to ltem 33
Q No
currently in effect. I
Enter an " X in the appropriate box:
I have received specialized training.

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D Yes

+ Go to ltem 34

Q No

+ Go to Section 6

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134 Enter the type of specialized training you received and the period of time you received it.

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TYPE

DATES

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Have you used any of this training in your work?

-

D Yes
D No

-

+ Go to ltem 36

Go to Section 6

Describe when and how you use(d) this training in your work.

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Page 5

Form AA-17b (06-04)

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lnformation About Your Daily Activities
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After each activity listed below, check the one box that best describes your ability to do that activity.
EASY - I can easily do the activity.
HARD - I can do the activity with difficulty or with help.
NOT AT ALL - I cannot do the activity even with help.
EASY HARD

ACTIVITY

CI

Sitting

EXPLANATION - Explain each "HARD" answer.

$:):,

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1 Standing
1 Walking
Eating
Bathing
Dressing (Tying Shoes,

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Other Bodily Needs
Indoor Chores (Meal
Preparation, Laundry,
Cleaning, Etc.)

1

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Outdoor Chores (shopping.
Yardwork, Etc.)
Driving a Motor Vehicle
Using Public Transportation

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Conducting Personal
Business (Talking to and

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Dealing with Other People)
Reading English (For
example, newspapers
and magazines)

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Writing English (For example,
notes and letters)

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Information About Your Work and Earnings
Work
Activities

39 Enter an " X in the appropriate box:

Yes --, Go to Note and Item 40

Have you ever been employed
or self-employed?

Q No

>

Go to Section 8

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Note: If you answered "Yes" and you are a widow(er) filing for a disability annuity,
also complete and return to the RRB Form G-251, Vocational Report.
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Form AA-17b (06-04)

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Page 6

Work for an
Employer
Last
12 Months

Enter an " X in the appropriate box:
I have worked for pay for an employer in the last
12 months. (Do not include any self-employment.)

-

0 Yes
0

--+

Go to Item 41

--)

Go to Item 43

Enter your earnings, before any deduction, for each month you have already worked this year. Then, starting with
the current month, enter your expected gross earnings for this month and each remaining month this year.
JANUARY

FEBRUARY

MARCH

APRIL

MAY

JLlNE

JULY

AUGUST

SEPTEMBER

OCTOBER

NOVEMBER

DECEMBER

Enter your earnings, before any deduction, for each month last year.
JANUARY

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FEBRUARY

MARCH

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JUNE

MAY

APRIL

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JULY

SellEmployment
Last

AUGUST

SEPTEMBER

OCTOBER

Enter an "X" in the appropriate box:
Have you been self-employed in the last 12 months? --+

0 Yes
0 No

NOVEMBER

--+

DECEMBER

Go to Item 44

--+ Go to ltem 46

Enter your net earnings for each month you have already worked this year. Then, starting with the current month,
enter your expected earnings for this month and each remaining month this year.
FEBRUARY

MARCH

APRIL

MAY

JUNE

JULY

AUGUST

SEPTEMBER

OCTOBER

NOVEMBER

DECEMBER

1 Enter your net earnings, before any deduction, for each month last year.

45

46

Work Next
12 Months

JANUARY

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

JULY

AUGUST

SEPTEMBER

OCTOBER

NOVEMBER

DECEMBER

Enter an " X in the appropriate box:
Do you expect to work during the next 12 months?
(Include self-employment, if any.)

>

0 Yes
0 NO

1

--+ Go to Item 47

--+ Go to Section 8

Enter the name and address of the
person or company for whom you
expect to work. (If self-employed,
>
enter "Self.")
Enter the date(s) you expect
to work. (For example, "June
and July," "Indefinitely Starting
9-96," etc.)

>

Enter the gross amount you expect
to earn. (If you are self-employed,
>
enter the net amount.)
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Form AA-17b (06-04)

General Information
I FilingAA-17 50 Enter an " X in the appropriate box:
or AA-18

Security
Benefits

Service
Pension

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Yes + Go to ltem 56

I am filing either Form AA-17 or Form AA-18 at
this time.

+ Go to ltem 51

No

>

0 Yes + Go to Item 52

Enter an "X" in the appropriate box:
I have filed, or expect to file, for monthly social
security disability benefits?

>

Enter the social security claim number
under which vou have filed or will file.

>

a No

Enter an "X" in the appropriate box:
I am receiving or expect to receive a pension or I have received
or expect to receive a lump-sum payment instead of a pension
based on my earnings from an agency of the Federal, state, or
local government. (Answer "NO" if your only government pension payments are social security, railroad retirement, veterans
affairs, worker's compensation, or black lung benefits. Also
answer "NO" if you received a lump-sum payment that was just
your contributions to the pension fund plus interest.)

+ Go t o ltem 53

a Yes + Go to ltem 54
+ Go to ltem 56

Q No

154 I amlwas an employee of the Federal Government.

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Yes

Q No

+ Go to Note and Item 56

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+ Go to ltem 55

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Note: I f answered "Yes, " also complete and return the RRB Form G-208, Public
Service Pension Questionnaire, and verification of your pension.
Enter an "X" in the appropriate box:
On my last day of employment, I was employed by a state or local
government or the military service and social security (FICA)
taxes were being deducted from my public service earnings.

Q Yes

&

a No

-+ Go t o Note and ltem 56

Go t o ltem 56

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Note: I f answered "No," also complete and return the RRB Form 6-208, Public
Service Pension Questionnaire, and verification of your pension.
Offense

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56

Enter an " X in the appropriate box:
Within the past 12 months, I have been imprisoned or
given a sentence of confinement due to a conviction for a
criminal offense.

+ Go to Item 57

Yes

a No

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Enter the date of the conviction.

~onth

+ Go to Section 9

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Day

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Year

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Enter an " X in the appropriate box:
Is your disability related to the commission of the
criminal offense?

59

Enter the date of the sentence of confinement.

1

160 Enter the date that confinement began.

II
61

-

Enter an " X in the appropriate box:
Is your disability related to your confinement?
Enter an 'X" in the appropriate box:
Has the confinement ended?

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63

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Month

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Day

~onth

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Day

Page 8

Year

+ Go t o ltem 63
+ Go to Section 9

Q No

Form AA-17b (06-04)

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[7 No
Q Yes

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0 Yes
D
I Year

Q Yes

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Enter the date confinement ended.

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~onth

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Day

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Year

Remarks

I Remarks 1 64 1 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 space to enter
any additional information that you feel may be important to include.

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Page 9

Form AA-17b (06-04)

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

65

Certification

a Yes ---+ Go to Note and
a No ---+ Go to Item

>

ltem 66

66

Note: I f answered "Yes, "your guardian or other representative 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 RRB, or if I fail to disclose earnings or report.employment of any kind to the RRB, I am committing a crime which is punishable
under Federal law.

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I have received the booklet RB-17bJ Widow(er)'s Disability Benefits. I understand that I am responsible for
reporting any events that would affect my annuity, as explained in that booklet.
I certify that the information I gave to the RRB on this application is true to the best of my knowledge.

1 I agree to immediately notify the RRB:
If I perform work for any employer, railroad or nonrailroad, or perform any self-employment work;
If my condition improves;
If I am confined in a jail, prison, penal institution, or correctional facility due to a conviction for a criminal offense.
If my address changes;
If l remarry;
If I file for social security benefits based on any person's earnings record;
If I begin to receive a pension from an agency of the Federal, state, or local government or
if my present payments change.

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I know that if I am receiving a disability annuity and fail to report work and earnings promptly, I am committing a
crime punishable by Federal law and may result in criminal prosecution and/or penalty deductions in my annuity payments.
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Signature
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(First Name, Middle Initial,
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Last Name)
Month
Day
Year

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Date

67 If this certification is signed by mark ("X) in ltem 66, two witnesses who know the person signing must sign
below, giving their full addresses and daytime telephone numbers.
a Signature of Witness

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Address (Number and Street)

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City, State, and ZIP Code
Telephone Number

Area Code

Daytime Telephone Number

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b Signature of Witness

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Address (Number and Street)

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City, State, and ZIP Code

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Telephone Number

Area Code

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Daytime Telephone Number

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Form AA-17b (06-04)

Page 10

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How To Return Your Application

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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 shown on page 12 of this
application. 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.

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Make one final check before you seal the envelope to ensure that the following are enclosed:

*
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*

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NEEDED PROOFS
THE APPLICATION FORM ITSELF
ADDITIONAL FORMS YOU WERE ASKED TO COMPLETE

Note: Make no entries on page 12, which is the receipt for your claim. After the RRB receives your application,
they will complete the blanks on the receipt and send it back to you. When it is returned to you, 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 filed this application, please contact us so
we can find out what is causing the delay.

PAPERWORK REDUCTION AND PRIVACY ACT NOTICE
The information asked for in this form is needed to determine your entitlement to benefits under the Railroad
Retirement Act. The RRB's authority for requesting this information is Section 7(b)(6) of the Railroad Retirement Act.
We estimate that this form takes and average of 40 to 50 minutes per response to complete, including the time for
reviewing the instructions, getting the needed data, and reviewing the completed form. Federal agencies may not
conduct or sponsor, and respondents are not required to respond to, a collection of information unless it displays a
valid OMB number. If you wish send comments regarding the accuracy of our estimate or any other aspect of this
form, including suggestions for reducing the completion time, to Chief of lnformation Resources Management,
Railroad Retirement Board, 844 North Rush Street, Chicago, IL 60611-2092.

COMPUTER MATCHING AND PRIVACY PROTECTION ACT NOTICE
The Computer Matching and Privacy Protection Act of 1988 requires the RRB to advise you that information you
have provided may be used, without your consent, in automated matching programs. These matching programs are
a computer comparison of RRB records with records kept by other Federal, state, or local governmental agencies.
lnformation from these matching programs can be used to establish or verify a person's eligibility for federally funded
or administered benefit programs and for repayment of payments or delinquent debts under these programs.

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Page 11

Form AA-17b (06-04)

EMPLOYEE'S NAME

APPLICANT'S NAME

RAILROAD RETIREMENT BOARD CLAIM NUMBER

DATE CLAIM RECEIVED

Your application for railroad retirement disability benefits has been received and will be processed as quickly as possible. If
you change your address, or if there is some other change that may affect your claim, you or your representative should
report the change. The changes to be reported are listed below. Always give us your claim number when writing or calling
about your claim. If you have any questions about your claim we will be glad to help you. If you need to personally visit one
of our field offices, please call for an appointment. You will not be refused service if you do not have an appointment, but
our staff can serve you better when an appointment is made. Most oftices are open to the public from 9:00 AM to 3:30 PM,
Monday through Friday.

Address - If your address changes.
Work - If I perform work for any employer, railroad or nonrailroad, or perform any self-employment work.
Remarriage - If you remarry.
Condition - If your condition improves.
Social Security - If you file for benefits on any person's earnings.
Criminal Offense - If you are confined in a jail, prison, penal institution, or correctional facility due to a conviction
for a criminal offense.
Public Service Pension - If you begin to receive a pension from an agency of the Federal, state, or local
government or if your present payments change.

When a change occurs after you are entitled to disability benefits, you should report the change at once. You or your
representative can make the reports by telephone, mail, or in person, whichever you prefer.

To report any of the above changes, contact:

b Railroad Retirement Board

B Telephone Number:

If for some reason you cannot contact that office, you should contact:

U S RAILROAD RETIREMENT BOARD
844 N RUSH ST
CHICAGO IL 60611-2092
~ r mAA-17b (06-04)

Page 12