AA-18 Application for Mother's/Father's and Child Annuity

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

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DO NOT WRITE IN THIS SPACE

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E:YF/LED

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Application
for Mother'slFather's
and Child's Annuity

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FORM APPROVED
O.M.B. No. 3220-0030

OFFICE NUMBER
1

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APPROVED

DATE CODED

APPLICATION NUMBER

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CODED BY

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Before you complete this application, be sure to read Part I of booklet RB-17, Survivor Annuities, which explains information you
will need to answer many of the questions in this application.
Please read 'Important Notices on page 16 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 10 for this
purpose. If you do not know the answer to a question, print "unknown" in the space provided for the answer.

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When entering dates, always use numbers. Also, be sure there is one number in each box. For example, you would enter
February 12, 2001, as:
DAY
YEAR
MONTH

012 112 2101011
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 fonn quickly, filling in only necessary
information. Ifno "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 vou are completina this application on behalf of someone else, vou must answer each auestion 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.
Employee 1
Identification

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EMPLOYEE'S NAME

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2

EMPLOYEE'S SOCIAL SECURITY NUMBER
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1 3 1 EMPLOYEE'S RAILROAD RETIREMENT CLAIM NUMBER
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Applicant
4
ldentiication
5

APPLICANT'S NAME
a

I 1 1
6

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*

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STREETADDRESS

b

CITYAND STATE

d

COUNTY

DAYI'IME TELEPHONE NUMBER

Form AA-18 (04-04) Destroy Prior Editions

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Information About The Employee

I If a railroad retirement survivor benefit was previously received by someone, go to Section 4; otherwise go to ltem 7.
8 Enter the state (or country if other than United States) which was the
employee's permanent home at the time of death.

Residence

+

If the employee was age 62 or older when he or she died, go to ltem 10.
9 Enter an " X in the appropriate box:
The employee was unable to work at the time of death because of an
illness or accident which occurred at least five months before death. +

Disability

Military
Service

,

IJ Yes

a No

Please read the section "Credit for Employee's Military Service" in Part V of the RB-17 booklet to find out
how active military service is determined.
10 Enter an "X" in the appropriate box:
The employeewas in active military service after September 7,1939.

Yes

a No

-

+ Go to Note and ltem II
+ Gotolteml3

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Note: If answered "Yes," you will have to submit proof of the employee's military
service. If you cannot submit proof show, in Section 10, the branch of the service
and the beginning and ending dates for each period of service.

11 Enter an " X in the appropriate box:
The employee had voluntary military service during the
period June 15,1948, through December 15, 1950.

a

+

Yes
No

+ Go to ltem 12
+ Gotolteml3

a Yes

12 Enter an "X" in the appropriate box:
The employee had non-railroad earnings after leaving the
military service and before returning to the railroad.

Recent
13 Regardless of whether the employee was retired at death, show the name and address of each railroad or
non-railroad employer for whom the employee performed any part-time or full-time work during the last 3
Employment

years he or she worked. Print the name and address of the most recent employer in 13a, the second in 13b,
and so on. Enter the date each job began and ended.
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Name and Address of Employer

1

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Began

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Address

Ended

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Month

Year

Month

Year

City, State, ZIP Code

b Name

Ended

Began

Address

Month

Month

Year

Year
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City, State, ZIP Code

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Address

Year

Month

Year

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a Yes -,Go to ltem 15

Iself14 Enter an " X in the appropriate box:
Employment
The employee was self-employed

during any of the last three calendar years.

0

+

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Form AA-18 (04-04)

Page 2

No

+ Gotolteml7

a Yes + Go to Item 16
a
to Item

15 Enter an "X" in the appropriate box:
The employee's net earnings from self-employment were
more than $400 in any of the last three calendar years.
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Ended

Month

City, State, ZIP Code

1

1

Began

+

a This year
a Last year

Self16 Enter an "X"in the appropriate box(es):
Employment
Show the year or years in which the employee's net

earnings from self-employment were more than $400.

1 Railroad

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Year before last

Answer ltems 17 and 18 only if the employee was alive on October 1, 1981, and he or she had at least
25 years of railroad service; otherwise go to ltem 19.

Employment

If the employee was alive on October 1, 1981, and had at least 25 years of railroad service, please read the
section "Requirements the Employee Must Have Met" in Part I of the RB-17 booklet to find out what special
conditions may apply.

/

Note: You may be requested to submit pmof to veriw the statements
made in ltems 17 and 18.

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17 Enter an "X" in the appropriate box:
The employee "involuntarily and without fault":

1

1

stopped working for his or her last railroad
employer on or after October I , 1975, or

+ 0

0

was on furlough, leave of absence status, or
absent because of injury on October 1, 1975,
and was never called back to work for that
employer.
18 Enter an "X" in the appropriate box:
The employee declined an offer from a railroad employer to return
to a job in the same "class or craft" as his or her last railroadjob. -->

Yes + Go t o ltem 18
No + Go t o ltem 19

O
O

Yes
No

1

Employee's I 9 Enter the requested information for each of the employee's marriages. Enter the most recent marriage in 19a,
Marriages
the second most recent in 19b, and so on.
-

-

Answer if Marriage Ended for Reason
Other than Employee's Death
Name of Employee's Wife
or Husband
(if wife, include
maiden name)

a

b

City and State
Married
(country if other
than United States)

Date
Married
Month Day

Year

Month Day

Year

How Marriage
Ended
(check one)

Date Marriage
Ended

0

Death Month
Day
Spouse's Death
Divorce
O Annulment

0 Employee's Death
Spouse's Death
Divorce
O Annulment

Month Day

City and State
Marriage Ended
(country if other
than United States)

Year

Year

a
C

1

Widow(er)

1

Month Day

a Employee's Death Month

Year

Day

Year

Spouse's Death
Divorce
Annulment
-

-

-

Answer ltem 20 only if you and the employee were divorced.
Please read the marriage requirements in Part I11 of the RB-17 booklet to find out what categories of
widow(er)s may be eligible for a railroad retirement annuity.
20 Enter an "X" in the appropriate box:
There is a widow(er) or remarried widow(er) who may be eligible
for a widow(er)'s annuity.
-

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Yes

>

0

No

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Page 3

Form AA-18 (04-04)

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21 Enter an "X" in the appropriate box:
The employee was survived by a parent.

*

Parents

1

22 Enter an " X in the appropriate box:
The parent was dependent on the employee
for one-half of his or her support.

a Yes +Go to Item 22
a No +Go t o Section 4
0

Yes

a No

+ Go t o ltem 23
+Go

t o Section 4

1 23 Enter the requested information for each dependent parent of the employee.

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1

Name of Parent

1

a

Month

1
b

Month

1

1
.

Address and Telephone Number

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Day

I Year
I ITelephone1Number (includearea code)

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/"dress

(

Year Address

Day -

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Date of Birth

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Telephone Number (include area code)
(

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25 Enter your Social security number.
(If none, enter "To be submitted.") 26 Enter an "X" in the appropriate box:
I am now, or was previously, married to
someone other than the employee.

a Yes + Go t o ltem 27
a No + Go t o Item 29

27 Enter the requested information for each of your marriages t o someone other than the employee.
Enter the most recent marriage in 27a, the second most recent in 27b, and so on.

Your Husband's or
Wife's Name and
Social Security Number
(do not show employee)

a

Name
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b

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1

Month Day

Year

Month Day

Year

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C Name

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Year

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Name

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Date
Married
Month Day

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City and State
Married
(country if
other than
United States)

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If Marriage Never Ended, Leave These Blank
How Marriage
Ended
(check one)

Date Marriage
Ended

D Spouse's Death Month
0 Divorce

Day

Annulment
Spouse's Death Month Day
Divorce
0 Annulment
Spouse's Death Month Day
Divorce
Annulment

a
a
a
a

City and State
Marriage Ended
(country if
other than
United States)

Year

Year

Year

28 Answer only if any of the social security numbers requested in ltem 27 are unknown. If more than one social
security number is unknown, enter in Section 9, the information requested in this item for each additional
unknown number.

a Enter the name of the husband or wife
whose social security number is unknown.

1 c Enter that husband's or wife's place of birth.
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Fonn AA-18 (04-04)

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Item 28 continues on the next oaae.
Page 4

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Marriages
(cont.)

d Enter that husband's or wife's father's name.

-

e Enter that husband's or wife's mother's maiden name. +
Support

If you and the employee were divorced, go to ltem 35.
29 Enter an " X in the appropriate box:
The employee and I were living together when the employee died.
If "Yes," and you are male, go to ltem 34. If "Yes," and you are female,
go to Item 35.
-

-

-

Enter the reason you and the employee
stopped living together.

O

No

+Go to ltem 30

1

Enter an "X" in the appropriate box:
The employee was making regular contributionsto my support when the
employee died. If "Yes," and you are male, go to ltem 34.
A
If "Yes," and you are female, go to Item 35.
(Note: Consider the following as contributions to support:
money, food, clothes, paying bills, providing rent-free housing.)
Enter an "X" in the appropriate box:
The employee was under a court order to contribute to my
support.
(Note: Answer "Yes" if there was a court order, even if
the employee was not obeying it.)
One-Half
Support

Yes

1
yes

No +Go

1
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to Item 33

.

Yes +Go to Item 35

I2

NO +GO

to ltem 35

Answer ltem 34 only if you are working or have ever worked in the railroad industry, and Items 29 or 32 was answered "Yes."
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Enter an " X in the appropriate box:
The employee's contributionsto me provided at least
one-half of the money needed to support me.

Yes +Go to Note and Item 35
No +Go

+

to Item 35

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Note: If answered "Yes," complete and return to the RRB,
Form G-134, Statement Regarding Contributions and Support.
Criminal
Offense

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

Yes +Go to Item 36

-+

No +Go to Section 5

Yes +Go to ltem 40

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

t

Page 5

No +Go to Section 5

Form AA-18 (04-04)

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Information About Children
Please read the section "Definition of a Child's Annuity" in the RB-I7 booklet to find out what categories of children may
be eligible for a railroad retirement annuity.
41 Print the requested information for every child for whom you are filing this application who may be entitled
to a child's annuity. Print the youngest child in a, the second youngest in b, and so on. Always complete f.
If a child does not have a social security number, enter "TO BE SUBMITTED."
Relationship to Employee
(Check One)

Child's Full Name and
Social Security Number

a Name

O Legitimate
O Adopted
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b Name

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d Name
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e Name
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f

1

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1
Children

win
Applicant

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Legal
Guardian

Month

0
O
O
O
O
O
0

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Day

Yes

Year

Adopted
Stepchild
Grandchild
Other

O
O
O
O

Legitimate
Adopted
Stepchild
Grandchild
Other

O No

Legitimate
Month

O
O

Stepchild
Grandchild
Other

O
O
O
0
O

Legitimate
Adopted
Stepchild
Grandchild
Other

Day

Yes

Year

O No

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Month

Day

0 Yes

Year

O No

O Legitimate
0 Adopted
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Date of Birth

Stepchild
Grandchild
Other

c Name

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Enter an "X" in the
Appropriate Box: The
Child is Living with Me

Month

Day

Yes

Year

O
Month

Day

No

Yes

Year

O

Within the past 12 months, a child named in a through e above has been imprisoned, or
given a sentence of confinement due to a conviction for a criminal offense. If the answer is
"Yes," a full explanation, including the name of the child, must be provided in Section 1 0 .

No

O Yes
No

-

If every child in ltem 41 is living with you, go t o ltem 43.
42 Print the requested information for every child in ltem 41 who is not living with you. Print the youngest child in 42a.
If you need more space use Section 10.
First Name
of Child

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Person with Whom Child now Lives
Child's Address

43 Enter an "X" in the appropriate box:
A court has appointed a legal guardian for a child in ltem 41.

Form AA-18 (04-04)

Page 6

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Name

-

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Relationship to Child

Yes -,Go t o Item 44
No -,Go t o ltem 45

44 Print the requested information for every child in ltem 41 who has a court-appointed legal guardian.
Print the youngest child in 44a, etc.
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First Name of Child

Name and Address of Guardian
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1 a Yes

45 Enter an "X" in the appropriate box:
One or more of the children in ltem 41 is or
has been married. -

-

Go to Item 46
NO +GO to ltem 47

46 Print the requested information for every child in ltem 41 who has ever been married.
Print the youngest child in 46a, etc.
Enter an "X" in the
Child's
Appropriate Box:
a

Month

Month

b

Day

Day

Year

Yes

NO

ayes

NO

Year

If "Legitimate" or "Adopted" was checked for every child in Item 41, go to Item 49.
47 Enter an "X" in the appropriate box:
Every "Grandchild or "Other Child" in ltem 41 was living
with the em~loveeat the time the em~loveedied.

a Yes

+ 0

Date Marriage Ended
if Child Is Not
Still Married
Year
Month Day
Month

Day

1

Year

-

I

Go t o ltem 49
No -Go t o ltem 48

48 Print the requested information for every "Grandchild" or "Other Child" in ltem 41 who was not living with the employee
at the time the employee died. Print the youngest child in 48a, etc. If you need more space use Section 10.

Person with Whom Child Lived at the Time the Employee Died

First Name
of Child

Name

Address

Relationship to Child
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Children
For Whom
You Are
Not Filing

49 Enter an "X" in the appropriate box:
There is a child for whom I am not filing this

0

Yes +Go t o ltem 50
to ltem 51

a No -Go

application who may be entitled to a child's annuity. I

50 Print the requested information for every child for whom you are not filing an application who may be entitled
to a child's annuity. Print the youngest child in 50a, the next youngest in Sob, and so on.
Child's Full Name

1

Reason for Not Filina

Page 7

Form AA-18 (04-04)

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Information About Applicant's Other Government Benefits
Public
Service
Pension

51 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. --

a Yes

+Go to ltem 52

0 No

+ Go to ltem 54

(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.)

a Yes +Go to Note and Item 54

52 Enter an "Xuin the appropriate box:
I amlwas an employee of the Federal Government.

0 No +Go to Item 53

If answered "Yes," complete and retum to the RRB, Form 6-208,
Public Service Pension Questionnaire, and verification of yourpension.
53 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.

--

a Yes + Go to Item 54
No

+ Go to Note and Item 54

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ote: If answered "No,"mmplete and return to the RRB, Form G-208,
Public Service Pension Questionnaire, and verification of yourpensbn.
Social
Security
BenefihFiled For

54 Enter an "X" in the appropriate box:
An application has been filed for monthly social security
benefits for me or a child. -

0 Yes +Go to ltem 55
+ 0 No +Go t o ltem 56

I 55 Enter the requested information for eve y family member for whom an application has been filed for
monthly social security benefits. Use as many lines as are needed beginning with 55a.
Family
Member

Social Security Number
Filed On

Person Whose
Record Was Filed On

a
- -

56 Enter an "X" in the appropriate box:
An application will be filed in the future for monthly
social security benefits for me or a child.

Security
BenefitsFuture
Filing

1

0

Yes +Go to ltem 57
No +Go t o ltem 59

57 Enter the name of the person on
whose record you are filing.

58 Enter that person's social security number.

Form AA-18 (04-04)

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Page 8

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Railroad
Retirement
Benefits

59 Enter an "X" in the appropriate box:
An application has been or will be filed within 90 days for
monthly railroad retirement benefits for me or a child based on the
____)
record of someone other than the employee.

a Yes Go to Item
a No +Go to Section 7
60

-+

-

a Yes +Go to ltem
a No Go to Section 7

60 Enter an "X"in the appropriate box:
The application has been or will be filed based on the record of
->
someone other than myself. --

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--

61 Enter the name of the person on whose record the
application has been or will be filed.

61

-+

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If only six numbers,
enter here

Prefix

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

->

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Information About Work And Earnings
Please read the section "How Earnings Affect An Annuity" in Part V of the RB-17 booklet to find out how work and earnings
can affect your railroad retirement annuity or a child's annuity. Also, please refer to Form G-77, How Earnings Affect
Payment of Survivor Annuities, for the exempt amounts to use when answering ltems 63 through 69. When answering
ltems 63 through 71, consider only yourself and the children listed in ltem 41.
Earnings
Last Year

Answer ltems 63 and 64 only if the employee died before January 1 of this year.
-

-

-

63 Enter an "X" in the appropriate box:
My total earnings, or the total earnings of a child, for all
employment last year were more than the annual earnings
exempt amount shown on Form G-77.

I

-

a Yes + Go to Item
No

-

+ Go to Item 65

64 Print the requested information for every family member whose total earnings for last year were more than the
annual earnings exempt amount shown on Form G-77. Use as many lines as needed beginning with 64a.

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2 Total Earnings for Last Year
(Show Dollars Only)
$

a 1 Family Member

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

1

64

4 Enter an " X next to each month last year in
which the family member did not earn more than
the monthly earnings exempt amount or perform
substantial services in self-employment.

Yes

>

Ll No

JAN^^^^^^
rTZqJULr-TGkq(rnrn
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b 1 Family Member

1

2 Total Earnings for Last Year
(Show Dollars Only)

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3 Enter an "Xuin the appropriate box:
The family member earned more than the monthly earnings
exempt amount in employment for hire or performed substantial
services in self-employment in every month last year.
4 Enter an "X" next to each month last year in
which the family member did not earn more than
the monthly earnings exempt amount or perform
substantial services in self-employment.
Page 9

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a yes
a No

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Form AA-18 (04-04)

c 1 Family Member

Earnings
Last Year
Con't

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2 Total Earnings for Last Year
(Show Dollars Only)
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3 Enter an "X" in the appropriate box:
The family member earned more than the monthly earnings
exempt amount in employment for hire or to performed substantial
services in self-employment in every month last year.

1

Earnings
This Year

? = I

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4 Enter an "X" next to each month last year in
which the family member did not earn more than
the monthly earnings exempt amount or perform
substantial services in self-employment.

a Yes

>

O No

rlJULImrTiElm

65 Enter an ' X in the appropriate box:
I expect my total earnings, or the total earnings of a child
for all employment this year to be more than the annual
earnings exempt amount.

Yes

0

+

No

+ Go to Itern 66
+ Go to Itern 67

be more than the annual earnings exempt amount. Use as many lines as needed beginning with 66a.
a 1 Family Member
2 Total Expected Eamings for This Year
(Show Dollars Only)

1

-

A N

3 Enter an " X in the appropriate box:'
The family member expects 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.
4 Enter an " X next to each month this year in which the
family member did not, or does not expect to, earn
more than the monthly earnings exempt amount or
perform substantial services in self-employment.

Ib

J
~

r

-

1

1 Family Member

O Yes
O No

-

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p

~

J

~

U

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2 Total Earnings for This Year
(Show Dollars Only)

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3 Enter an "X" in the appropriate box:
The family member expects 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.
-

1

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4 Enter an "X'' next to each month this year in which the
familv member did not. or does not expect to, earn
morethan the monthly earnings e x e h t amount or
perform substantial services in self-employment.

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c 1 Family Member

O

>

J

Yes
No

A

N

2 Total Earnings for This Year
(Show Dollars Only)
$

-

3 Enter an " X in the appropriate box:
The family member expects 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. --------4 Enter an "X" next to each month this year in which the
family member did not, or does not expect to, earn
more than the monthly earnings exempt amount or
perform substantial services in self-employment.
I

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a Yes
O

No

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ote: If there are two or more children qualified to receive benefits and you are earning more than
the annual earnings exempt amount, please contact the RRB field office. Someone will be able to
help you decide whether it is better for you to file for yourself and the children, or whether you would
actually be better off to file for the children alone.
Form AA-18 (04-04)

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Page 10

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

Earnings
Next Year

(Year)

1

m Yes + Go to ltem 68
m No + Go to ltem 70

-

68 Enter an " X in the appropriate box:
I expect my total earnings, or the total earnings of
a child, from all employment next year to be more
than the annual earnings exempt amount.

-

0

Yes + Go to ltem 69
No + Go to ltem 70

69 Enter the requested information foTevery family member whose total earnings for next year are expected to be
more than the annual earninas exem~tamount. Use as manv blanks as are needed beainnina with 69a.
-

-

-

Expected Earnings
Expected Earnings
Family
Family
for Next Year
for Next Year
Member
Member
(Show
Dollars
Only)
(Show
Dollars Only)
-

70 Enter an "X"in the appropriate box:
I have worked, or a child has worked, for a railroad

Railroad
Work

Family
Member

0

1
1

for Next Year

Yes + Go to ltem 71
No + Go to Section 8

1

1 71 Enter the requested information for every family member who has worked for a railroad or other employer

1

in the railroad industry. Use as many lines as needed beginning with 71a.
a 1 Family Member
2 Railroad Employer

3 Date Last Worked
Month

1

Day

1

-

-

5 If you expect the annuity to begin before January 1
of this year, enter an "X.next to each month of last
year during which the family member worked for an
employer in the railroad industry. -

1

1

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2 Railroad Employer

3 Date Last Worked
Month

1

Year

4 Enter an " X next to each month in this year during
which the family member worked for an employer in
the railroad industry.

b 1 Family Member

1

I
I

I

1

i

4 Enter an "X.next to each month in this year during
which the family member worked for an employer
in
~.
the railroad industry.
-

,-

I

5 If you expect the annuity to begin before January 1
of this year, enter an "X"next to each month of last
year during which the family member worked for an
employer in the railroad industry.

c 1 Family Member

JAN

2 Railroad Employer

-

4 Enter an "X' next to each month in this year during
which the family member worked for an employer in
the railroad industry.
-

IAUGI)I

~ J U L ~

1

Day

I

Year

1(
-

~ O C T ~ ~I N O V ~ I D E C ~ ~

~~IIYAR/(~APR~~I

+~
3 Date Last Worked

P
I

~

~

5 If you expect the annuity to begin before January 1

of this year, enter an " X next to each month of last
year during which the family member worked for an
employer in the railroad industry.
------

Page 11

Form AA-18 (04-04)

Filing
Protection

Answer 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.
72 Enter an "X" in the appropriate box:
I also want this application used to protect my
filing date for social security benefits.

Yes
C1 No

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 10,
or call your financial institution for the information you need to complete Items 73-77. If you do not have a bank account, or
receiving your payments by Direct Deposit would cause you a hardship go to Item 78.
I

1 Direct

73 Enter the name of your financial institution.

Deposit

-+

1 AREA CODE I

TELEPHONE NUMBER

74 Enter the telephone number of your financial institution.

-

75 Enter the routing transit number of your financial institution.
76 Enter your account number.

-

>

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

I
I

I I I I I I I I

m Checking
m Savings

-

78 Check this box if you do not have a checking or savings account,
or if Direct Dewsit would cause vou a hardshio.

Go to Section 10

>I

Remarks
I

IRemarks

1

1 79 This section is to be used for the continuation of answers to other items. Be sure to include the item number

1

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.

Form AA-18 (04-04)

Page 12

Certification
Ceffication

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

+

0

Yes + Go to Note and ltem 81
No + Go to ltem 81

Note: If answered "Yes," your guardian or other representative
must sign this application. That person must also complete and
return Form AA-5, Application for Substitution o f Payee.

81 1 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 booklet RB-17, Survivor Annuity, and the booklet, RB-Ss, Events That Affect A Survivor
Annuity. I understand that I am responsible for reporting any events that would affect my annuity as explained in
those booklets.

I

I

I

I certify that the information I gave to the RRB on this application is true to the best of my knowledge.
I agree to immediately notify the RRB:
If l marry;
If I begin to receive a pension from an agency of the Federal, state, or local government, or if my
present payments change;
If an application is filed for social security benefits for me or any child based on any person's earnings record;
If I or any child go to work for an employer in the railroad industry;
If I or any child will earn more than the annual earnings exempt amount, and it was not reported on the
application;
If I reported expected earnings for myself or any child and that earnings estimate changes;
If my address changes;
If any child for whom I am receiving benefits dies, marries, or leaves my care;
a If I am, or any child is, confined in a jail, prison, penal institution, or correctional institution due to a conviction
for a criminal offense.
I
Signature
w

I

-

(First Name, Middle Initial,
Last Name)

Month

Date

Day

Year

82 If this certification is signed by mark ("X") in ltem 81, two witnesses who know the person signing must sign
below, giving their full addresses and daytime telephone numbers.
a. Signature of Witness

I

Address (Number and Street)
I

City, State, ZIP Code

Daytime Telephone Number (include area code)

-

Area Code

-

Area Code

Telephone Number
I

I
1

I

b. Signature of Witness

Address (Number and Street)

I '

City, State, ZIP Code

Daytime Telephone Number (include area code)

Page 13

Telephone Number

Form AA-18 (04-04)

I

I

1

How To Return Your Application
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 ofice shown on
page 15 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.
Make one final check before you seal the envelope to ensure that the following are enclosed:

>- NEEDED PROOFS

*

THE APPLICATION FORM ITSELF
ADDITIONAL FORMS YOU WERE ASKED TO COMPLETE

/
\

Note: Make no entries on page 15, 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.

Form AA-18 (04-04)

Page 14

\
I

Employee's Name

Applicant's Name

Railroad Retirement Board Claim Number

Date Claim Received

Your application for a railroad retirement mother'sifather's and child's annuity has been received and will be processed as
quickly as possible. If you do not receive your first payment by
, you should contact the servicing field
office shown below. 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
l glad to help you. If you
when writing or calling about your claim. If you have any questions about your claim, we w ~ lbe
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 offices are open to the public
from 9:00 AM to 3:30 PM, Monday through Friday.

Marriage-If

you marry.

Child Earning-If
any child's total earnings or selfemployment status changes from what was reported on
this application.

Public Pension-If you begin to receive a pension
from an agency of the Federal, state, or local goverm
ment, or if your present payments change.

Work-If you or any chlid go to work for an employer in the
railroad industry.

Social Security-If an application is filed for social
security benefits for YOU or a child based on any person's earnings record.
Address-If your address changes, even if your payments are sent to a financial organization.
Earnings-If your earnings change. On your application
you told us you expected total earnings for
to be
.
You
(are)
(are
not)
earning
more
than
$
a month. You (are) (are not) performing
$
substantial services in self-employment.

Applicant i s i n Your Care-If any person for
whom you are receiving an annuity dies marries, or
leaves your care.
Criminal Offense--If you or any child are confined in a
jail, prison, penal institution, or corre~tionalfacility due
to a conviction for a criminal offense.

Report at once if work pattern changes.

When a change occurs after you have begun receiving your annuity, you should report the change at once. You or
your representative can make the reports by telephone, mail, or in person, whichever you prefer. In addition, an annual
report of earnings must be filed with the Railroad Retirement Board within 3 months and 15 days after the end of any
taxable year in which you earned more than the exempt amount.
The annual report of earnings is required by law and failure to report may result in the loss of one or more monthly benefits.

To report any of the above changes, contact:
Railroad Retirement Board

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
Page 15

Form AA-18 (04-04)

Paperwork Reduction and Privacy Act Notice
This notice is given under the Paperwork Reduction Act of
1995 and the Privacy Act of 1974. The Privacy Act requires
that the Railroad Retirement Board (RRB) tell you the following
whenever we ask you for information.

Office of Personnel Management, Department of Veterans
Affairs, or Federal, state, or local welfare or public aid agencies
to determine if you can receive benefits from these organizations and if any previous benefits were paid incorrectly.

1) The law which allows us to ask for the information;

8) The Internal Revenue Service or to state and local taxing
authorities for figuring your taxes and for use in audits.

2) whether that law requires you to give us that information
and what, if anything, might happen to you if you do not give it
to us;

9) Your last address and the name of your last employer may
be released to the Department of Health and Human Services
to be used in the Parent Locator Service.

3) the reason why the information is requested; and

10) The General Accounting Office for audits and for collecting
overpayments owed to the RRB or the Social Security
Administration.

4) the persons, organizations, and agencies to which we may
release the information without your permission.

The RRB's authority for requesting this information is Section
7(b) of the Railroad Retirement Act of 1974. Providing us with
this information is voluntary on your part. However, if you fail to
provide us with the requested information we may be unable to
pay you any benefits. The RRB needs this information to determine whether you are eligible to receive such benefits and, if
so, the amount you are entitled to receive. If your annuity application is approved and we begin to pay you benefits, information that we may request from you in the future will be used to
determine whether you are entitled to continue to receive such
benefits.

11) The U.S. Department of Labor as required by the Federal
Coal Mine and Safety Act.
12) In certain cases for law enforcement purposes and for
court proceedings.
13) lnformation about the determination and recovery of an
overpayment made to you may be released to any other person from whom any portion of the overpayment is being recovered.
14) Your name and address may be released to a Member of
Congress to inform you about current or proposed legislation
which could affect the railroad retirement system.

Although the information we request is almost never used for
any purpose other than the payment of benefits under the
Railroad Retirement Act, the RRB does have the authority to
release information to the indicated individuals, organizations,
and/or agencies listed below without your approval:
1) An attorney, the Office of the President, a Congressional
office, a labor union or the Department of State's embassy or
consular offices if they allege to be representing you at your
request.

15) Professional Standard Review Organizations and State
Licensing Boards when services provided by physicians or
practitioners suggest unethical or unprofessional conduct.

3) A person who will receive benefits on your behalf if the RRB
decided that some medical condition keeps you from receiving
your own benefits; such information may also be released in
determining whether such a medical condition exists and who
is suitable to receive such benefits for you.

We estimate this form takes an average of 27 to 47 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 completion time, to Chief of lnformation Management,
Railroad Retirement Board, 844 North Rush Street, Chicago,
Illinois 6061 1-2092.

4) To people or organizations who are working for the RRB;
such information may include medical records.

Computer Matching and Privacy Protection Act Notice

2) Other people who are receiving benefits based on the same
railroad retirement account as you are if the information affects
their payments from the RRB.

5) 'The U.S. Treasury Department or U.S. Postal Service to
issue payments and to investigate lost, forged, or stolen checks.

6) Your last employer to make sure that you are eligible to
receive railroad retirement benefits and you continue to receive
any available medical benefits, and to any railroad industry
employer (or to its insurance company) to make sure that you
can receive any private retirement or insurance benefits which
may be offered by the employer.
7 ) The Social Security Administration, Centers for Medicare &
Medicaid Services, Pension Benefit Guarantee Corporation,
Form AA-18 (04-04)

The Computer Matching and Privacy Protection Act of 1988
requires the Railroad Retirement Board (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
usedto 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.

Page I 6