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pdfUNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD
FORM APPROVED
O.M.B. No. 3220-0030
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DO NOT WRITE IN THIS SPACE
OFFICIALLY FILED
OFFICE NUMBER
APPLICATION
FOR
CHILD'S ANNUITY
APPROVED
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APPLICATION NUMBER
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DATE CODED
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CODED BY
General Instructions
Before you complete this application, be sure to read Part 1 of booklet RB-17, Survivor Annuities, which explains information
you will need to answer many of the questions in this application.
If filing for a child's disability also complete Form AA-19a. If filing for a student's annuity also complete Form G-315.
Please read "Important Notices" on page 14 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.
When entering dates, always use numbers. Also, be sure there is one number in each box. For example, you would enter
February 13,2000, as:
MONTH
DAY
YEAR
012
I13 2101010-
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.
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If you are completing
on behalf of the child, you must answer each question as it applies
to the child.
- this application
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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.
P- If the information is not correct, cross out the incorrect information and enter the correct information above it.
P- If the information is missing, fill it in.
Employee
Identification I EMPLOYEE'S NAME
2
EMPLOYEE'S SOCIAL SECLlRlTY NUMBER
3
EMPLOYEE'S RAILROAD RETIREMENT CLAIM NUMBER
Applicant
4
Identification
5
6
1
APPLICANT'S NAME
-
+
a
STREET ADDRESS
b
CITYANDSTATE
c
ZIP CODE
d
COUNTY
+
+
DAYTIME TELEPHONE NUMBER
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Form AA-19 (05-04) Destroy Prior Editions
Information About The Employee
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p
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Birth Date 1 7 Enter the employee's date of birth.
MONTH
DAY
YEAR
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Residence
8 Enter the state (or country if other than United States) which
was the employee's permanent home at the time of death.
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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.
Military
Service
Q Yes
Q No
Please read the section "Credit for Employee's Military Sewice" in the RB-17 booklet to find out how active
military service is determined.
10 Enter an " X in the appropriate box:
The employee was in active military service after
September 7, 1939.
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Yes + Go to Note and ltem 11
No + Go to ltem 13
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(blote: If answered uYes,lJyouwill have to submit proof of the employeeS militdry service. I f p u cannot submit
proof, show the branch of the sewice and the beginning and ending dates for each period of service in Section 10.
11 Enter an "X" in the appropriate box:
The employee had voluntary military service during the
period June 15, 1948, through December 15, 1950.
CL Yes +Go to ltem 12
CL No +Gotoltem13
12 Enter an "X" in the appropriate box:
The employee had nonrailroad earnings after leaving the military
service and before returning to the railroad.
a Yes
CL No
13 Regardless of whether the employee was retired at death, show the name and address of each railroad or non-
Employment railroad employer for whom the employee performed any part-time or full-time work during the last 3 years he
Recent
or she worked. Print the name and address of the most recent employer in a, the second in b, and so on.
Enter the date each job began and ended.
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Name and Address of Employer
Began
Month
Year
a. Name
Street Address
1
Began
Month
Year
City, State & ZIP Code
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Employment
City, State & ZIP Code
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Ended
Month
Year
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CL Yes +Go to ltem 15
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.
CL Yes+
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IJ No +Go to Item 17
Goto Item 16
No + Go to ltem 17
Q This year
Q Last year
Q Year before last
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Form AA-19 (05-04)
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Ended
Month
Year
14 Enter an " X in the appropriate box:
The employee was self-employed during any of the
last three calendar years.
16 Enter an "X" in the appropriate box(es) to show the year
or years in which the employee's net earnings from
self-employment were more than $400.
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Began
Year
Month
c. Name
Street Address
Ended
Month
Year
City, State & ZIP Code
b. Name
Street Address
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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.
Railroad
Please read the section "Requirements The Employee Must Have Met" in the RB-17 booklet to find out what special conditions may apply if the employee was alive on October 1, 1981, and had at least 25 years of railroad service.
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Note: You may be requested to submit proof to verify the statements made in Items 17 and 18.
17 Enter an " X in the appropriate box:
The employee "involuntarily and without fault":
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8
stopped working for his or her last railroad employer on or
after October I,1975, or
was on furlough, leave of absence status, or absent because
of injury on October I , 1975, and was never called back to
work for that employer.
a Yes
a No
--+ Go to Item 18
--+ Go to Item 19
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 railroad job.
Yes
a No
Employee's 19 Print the requested information for each of the employee's marriages. Print the most recent in a, the second
Marriages
most recent in b, 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)
Date
Married
Month
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Parents
City and State
Married
(country if other
than United States)
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Day
I Year
a
a
a
a
a
a
a
a
a
a
a
a
How Marriage
Ended
(Check One)
City and State
Marriage Ended
(country if other than
United States)
Date Marriage
Ended
Employee's Death
Spouse's Death
Divorce
Annulment
Month
Day
Year
Em~lo~ee's
Death
Spouse's Death
Divorce
Annulment
Month
Day
Year
Employee's Death
Spouse's Death
Divorce
Annulment
Month
Day
Year
Please read the section "Definition Of A Widow(er)'s Annuity" in the RB-17 booklet to find out what categories of
widow(er1 may be eligible for a railroad retirement annuitv.
20 Enter an "X" in the appropriate box:
There is a widow(er), remarried widow(er), or surviving divorced
spouse who may be eligible for a widow(er)'s annuity.
21 Enter an " X in the appropriate box:
The employee was survived by a parent.
a Yes
a No
a Yes
a No
a Yes
-
22 Enter an "X" in the appropriate box:
The parent was dependent on the employee for
one-half of his or her support.
--+ Go to ltem 22
--+ Go to Section 4
--+ Go t o Item 23
No --+ Go t o Section 4
23 Print the requested information for each dependent parent of the employee.
Name of Parent
a
Address and Telephone Number
Date of Birth
Month
Year
Day -
Address
Telephone Number (include area code)
(
)
Address
Month
Year
Day
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Telephone Number (include area code)
Page 3
Form AA-19 (05-04
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Information About Children
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Please read the section "Definition OfA Child's Annuity" in the RB-17 booklet to find out what categories of children may be
eligible for a railroad retirement annuity.
Children
24 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. If a child does not have a
social security number, enter "TO B E SUBMITTED."
Note: If Stepchild or Grandchildis checked below, you must also complete Form G-139, Statement
Regarding Contributions and Support of Children.
Child's Full Name and
Social Security Number
a
Relationship to
Employee
(Check One)
a
Legitimate a Grandchild
a Adopted
a Stepchild a Other
a Adopted
Legitimate a Grandchild
a
a Stepchild a Other
a Legitimate a Grandchild
a Adopted
a Stepchild a Other
a Legitimate a Grandchild
a Adopted a Other
a Stepchild
a Legitimate a Grandchild
a Stepchild
b
C
d
e
Enter an 'X" in the
appropriate box:
The Child is Living
with Me
Date of Birth
Day
Year
Month
Day
Year
Month
Day
Year
Month
Day
Year
Month
Day
Year
Month
0 Yes
a No
a Yes
a No
a Yes
a No
a Yes
a No
a Yes
a No
I If every child in Item 24 is living with you, go to Item 26.
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Children
Not Living
With
Applicant
25 Print the requested information for every child in ltem 24 who is not living with you. Print the youngest in a.
Legal
Guardian
26 Enter an "X" in the appropriate box:
A court has appointed a legal guardian for a child in ltem 24.
P e r s o n with W h o m C h i l d i s Living
First Name
of Child
Child's Address
Name
Relationship to
Child
a Yes +Go to ltem 27
a No +Go to ltem 28
27 Print the requested information for every child in ltem 24 who has a court-appointed legal guardian.
Print the youngest child in a, etc.
First Name of Child
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Form AA-19 (05-04)
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Name and Address of Guardian
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Page 4
Married
Children
a Yes +Go t o ltem 29
28 Enter an "X" in the appropriate box:
One or more of the children in ltem 24 is or has been married.
Q No +Go t o ltem 30
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29 Print the requested information for every child in ltem 24 who has ever been married. Print the youngest child in a.
Child's Married Name
GrandChildren,
Other
Children
Date Married
Date Marriage Ended
if applicable
..
a
Month
Day
Year
Month
Day
Year
b
Month
Day
Year
Month
Day
Year
If "Legitimate" or "Adopted" was checked for every child in ltem 24, go to ltem 32.
a Yes +Go t o ltem 32
a No +Go to ltem 31
30 Enter an " X in the appropriate box:
Every "Grandchild" or "Other Child in ltem 24
was living with the employee at the time the employee died.
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31 Print the requested information for every "Grandchild or "Other Child" in ltem 24 who was not living with the
employee at the time the employee died. Print the youngest child in a, etc.
Person with Whom Child Lived at the Time the Employee Died
First Name of Child
Name
Address
Relationship to Child
a
b
Children
For Whom
You Are
Not Filing
a Yes +Go t o ltem 33
a No +Go t o ltem 34
32 Enter an "X" in the appropriate box:
There is a child for whom I am not filing this application
who may be entitled to a child's annuity.
33 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 a, the next youngest in b, and so on.
Reason for Not Filing
Child's Full Name
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Information About The Applicant
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Identification 34 Enter an "X" in the appropriate box:
I am a child filing for myself.
Relationship
35 Print your relationship to the youngest child in ltem 24.
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36 Enter an "X" in the appropriate box:
My relationship to every child in ltem 24 is the same.
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Page 5
a Yes +Go t o ltem 39
a No +Go t o ltem 35
a Yes +Go t o ltem 38
a No +Go t o ltem 37
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Form AA-19 (05-04)
Relationship 37 Print the requested information for every child for whom your relationship differs.
Con't
Your Relationship to Child
Child's Name
Social
38 Enter your social security number if you are the
Security
parent of at least one child in ltem 24.
Number
Criminal 39 Enter an "X" in the appropriate box:
Offense
Q Yes +Go to Item 40
Q No +Go to Section 6
Within the past 12 months, a child named in ltem 24 has been imprisoned or
given a sentence of confinement due to a conviction for a criminal offense.
140 Enter the date of the conviction.
41 Enter the date of the sentence of confinement.
Month
Day
Year
Month
Day
Year
Month
4 2 Enter the date that confinement began.
1
Day
I
Year
Q Yes +Go to ltem 44
Q No +Go to Section 6
43 Enter an "X" in the appropriate box:
Has the confinement ended?
Month
44 Enter the date confinement ended.
Day
Year
Information About Applicant's Other Government Benefits
When answering Items 45 through 52, consider only the children listed in ltem 24.
Social
Security
BenefitsFiled For
45 Enter an " X in the appropriate box:
An application has been filed for benefits under the Social
Security Act for any child.
Q Yes +Go to Item 46
Q No +Go to Item 47
46 Print the requested information for every child for whom a social security application has been filed. Use as
many lines as needed beginning with a.
Child's Name
Social
Security
BenefitsFuture
Filing
1
Person Whose Record
was Filed On
47 Enter an "X" in the appropriate box:
An application will be filed in the future for benefits
under the Social Security Act for any child.
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Social Security Number Filed On
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Q Yes +Go to ltem 48
Q No +Go to ltem 50
48 Print the name of the person on whose record the child
will file.
49 Enter that person's social security number.
Railroad
50 Enter an "X" in the appropriate box:
Retirement
An application has been filed or will be filed for monthly
Benefits
Q Yes +Go to ltem 51
Q No +Go to Section 7
railroad retirement benefits for any child based on
someone other than the employee.
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'arm AA-19 (05-04)
Page 6
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Railroad / 51 Print the name of the ~ e r s o n
on whose record the
Retirement
application has been kled or will be filed.
Benefits
Con't
52 Enter that person's Railroad Retirement Board claim
If only six numbers,
enter here
Prefix
number, including the letter prefix.
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Information About Work And Earnings
Please read the section "How Earnings Affect An Annuity" in the RB-17 booklet to find out how work and earnings can affect 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 53 through 59.
When answering ltems 53 through 61, consider only the children listed in ltem 24.
Answer ltems 53 and 54 only if the employee died before January 1 of this year.
Earnings
Last Year
53 Enter an "X"in the appropriate box:
The total earnings of any child for all employment last year were
more than the annual earnings exempt amount shown on Form G-77.
Yes -+ Go to ltem 54
No -+ Go to ltem 55
54 Print the requested information for every child whose total earnings for last year were more than the annual
earnirlgs exempt amount shown on ~ o r m
G-77. Use as many lines as needed beginning with a.
1
1
a I Child's Name
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2 Total Earnings for Last Year
(Show ~ o l l a i sOnly)
$
3 Enter an "X" in the appropriate box:
Did the child earn more than the monthly earnings exempt amount in
employment for hire or perform substantial services in self-employment in
every month last year?
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4 Enter an "X" next to each month last year in
which the child did not earn more than the
monthly earnings exempt amount or perform
substantial services in self-employment.
O Yes
O No
I-pq~~~pqrpiqrpq
2 Total Earnings for Last Year
(Show Dollars Only)
$
1 Child's Name
I
3 Enter an "Xuin the appropriate box:
Did the child earn more than the monthly earnings exempt amount in
employment for hire or perform substantial services in self-employment in
every month last year?
Yes
O No
4 Enter an "X" next to each month last year in
which the child did not earn more than the
monthly earnings exempt amount or perform
substantial services in self-employment.
2 Total Earnings for Last Year
(Show Dollars Only)
$
1 Child's Name
I
3 Enter an "X" in the appropriate box:
Did the child earn more than the monthly earnings exempt amount in
employment for hire or perform substantial services in self-employment in
every month last year?
Yes
O No
4 Enter an "X" next to each month last year in
which the child did not earn more than the
monthly earnings exempt amount or perform
substantial services in self-employment.
Earnings
This Year
Near\
.
55 Enter an "X" in the appropriate box:
The total earnings of any child for all employment this year
will be more than the annual earnings exempt amount.
Yes -+ Go to ltem 56
No -+ Go to ltem 57
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Page 7
Form AA-19 (05-04
Earnings
This Year
Con't
56 Print the requested information for every child whose total earnings for this year are expected to be more
than the annual earnings exempt amount. Use as many lines as needed beginning with a.
a 1 Child's Name
2 Total Earnings for This Year
(Show Dollars Only)
$
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1
3 Enter an "X"in the appropriate box:
Did the child earn more than the monthly earnings exempt amount in
employment for hire or perform substantial services in self-employment in
every month this year?
Yes
O No
4 Enter an "X"next to each month this year in
which the child did not, or does not expect to,
earn more than the monthly earnings exempt
amount or perform substantial services in
self-employment.
1
2 Total Earnings for This Year
(Show Dollars Only)
$
b I Child's Name
3 Enter an "Xnin the appropriate box:
Did the child earn more than the monthly earnings exempt amount in
employment for hire or perform substantial services in self-employment in
everv month this vear?
4 Enter an "X" next to each month this year in
which the child did not, or does not expect to,
earn more than the monthly earnings exempt
amount or perform substantial services in
self-emplovment.
. -
Yes
O No
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2 Total Earnings for This Year
(Show Dollars Only)
$
1 Child's Name
I
3 Enter an "X" in the appropriate box:
Did the child earn more than the monthly earnings exempt amount in
employment for hire or perform substantial services in self-employment in
every month this year?
Yes
O No
4 Enter an "X" next to each month this year in
which the child did not, or does not expect to,
earn more than the monthly earnings exempt
amount or perform substantial services in
self-employment.
Earnings
Next Year
(Year)
57 Enter an "X" in the appropriate box:
This application is being returned in September,
October. November, or December.
Yes +Go t o ltem 58
No +Go t o ltem 60
58 Enter an "Xuin the appropriate box:
The total earnings of any child for,all employment next year will be
more than this year's annual earninas exempt amount.
Yes +Go to Item 59
No +Go to ltem 60
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59 Enter the requested information for every child whose total earnings for next year are expected to be more
than the annual earnings exempt amount. Use as many blanks as needed beginning with a.
Expected Earnings Next Year
Child's Name
(Show Dollars OnM
1
$
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Page 8
O Yes +Go to Item 61
O No +Go to Section 8
60 Enter an "X" in the appropriate box:
Any child has worked for a railroad or other employer in
the railroad industry.
61 Print the requested information for every child who has worked for a railroad or other employer in the railroad
industry. Use as many lines as are needed beginning with a.
a
1 Child's Name
2 Railroad Employer
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1 Month 1
3 Date Last Worked
4 Enter an "Xunext to each month in this year
during which the child worked for an employer
in the railroad industry.
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Year
1
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1
r--piqJULllI*UGrpq~l(rTiq
5 If you expect the annuity to begin before January 1st
of this year, enter an "X' next to each month of the
last year during which the child worked for an
employer in the railroad industry.
b
Day
JAN
~
1 Child's Name
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2 Railroad Employer
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I Month 1
3 Date Last Worked
Day
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Year
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4 Enter an " X next to each month in this year
during which the child worked for an employer
in the railroad industry.
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1
W
I
r-pqrpiiqrplrpqmm
5 If you expect the annuity to begin before January 1st
of this year, enter an "X" next to each month of the
last year during which the child worked for an
employer in the railroad industry.
1
~
1 Child's Name
~
~
r
2 Railroad Employer
I
Month
3 Date Last Worked
1
Day
I
4 Enter an " X next to each month in this year
during which the child worked for an employer
in the railroad industry.
5 If you expect the annuity to begin before January 1st
of this year, enter an " X next to each month of the
last year during which the child worked for an
employer in the railroad industry.
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Year
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/MARlr
~ I J U L l l ~ ~ - p
1
ml
1
~
~
~
r
p
7
Filing Date
Answer only if you are disabled or otherwise eligible for social security disability or survivor benefits and you have not filed
an application for such benefits.
Filing
Protection
62 Enter an " X in the appropriate box:
I also want this application used to protect my filing date
for social security benefits.
Page 9
0 Yes
O No
Form AA-19 (05-04
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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 10,
or call your financial institution for the information you need to complete Items 63-67. If you do not have a bank account, or
receiving your payments by Direct Deposit would cause you a hardship, go to Item 68.
Direct
Deposit
63 Print the name of your financial institution.
Area Code
64 Print the telephone number (including area code)
of your financial institution.
.Telephone Number
65 Print the routing transit number of your
financial institution.
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66 Print your account number.
a Checking
67 Enter an " X in the appropriate box:
Type of account for the above account number.
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Savings
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Go To Section 10
68 Check this box if you do not have a checking or
savings account, or if Direct Deposit would
cause you a hardship.
Remarks
Remarks
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69 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.
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Form AA-19 (05-04)
Page 10
1
Certification
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70 Enter an " X in the appropriate box:
I will have a guardian or other representative sign
this application on my behalf.
a Yes +Go to Note and ltem 71
No
+Go to ltem 71
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 of Payee.
71 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 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 I / any child marries;
If I / any child over age 18 ceases to attend school full time;
If an application is filed for social security benefits on any person's earnings record;
If I / any child goes to work for an employer in the railroad industry;
If I/any child will earn more than the annual earnings exempt amount, and it was not reported on the
application;
If the reported earnings estimate changes;
If my address changes;
If any child for whom I am receiving benefits dies or leaves my care;
If I am, orany child is, confined in a jail, prison, penal institution, or correctional institution due to a
conviction for a criminal offense.
Signature
(First Name, Middle Initial,
Last Name)
b
Month
Date
Day
Year
b
'2 If this certification is signed by mark ("X) in ltem 71, two witnesses who know the person signing must sign
below, giving their full addresses and daytime telephone numbers.
a. Signature of Witness
Address (Number and Street)
City, State, and ZIP Code
Telephone Number
Area Code
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Daytime Telephone Number
b. Signature of Witness
Address (Number and Street)
City, State, and ZIP Code
Area Code
Telephone Number
Daytime Telephone Number
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Page 11
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Form AA-19 (05-01
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 the child's 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
13 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
ADDl1-IONAL FORMS YOU WERE ASKED TO COMPLETE
/
Note: Make no entries on page 13, which is the receipt for your claim. ARer the RRB office
receives the child's 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 the application and has
started the work needed to determine if the child is entitled to benefits. If you do not receive your
receipt within two weeks aRer you filed this application, please contact us so we can find out what
is causing the delay.
)rm AA-19 (05-04)
Page 12
Employee's Name
4pplicant's Name
Railroad Retirement Board Claim Number
Date Claim Received
Your application for a railroad retirement 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
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 offices are open to the public
from 9:00 AM to 3:30 PM, Monday through Friday.
Work-If a child goes to work for an employer in the
railroad industry.
Death-If any child dies.
Marriage-If any child marries.
Address-If your address changes, even if your payments
are sent to a financial organization.
Social Security-If an application is filed for
social security benefits for any child based on
any person's earnings record.
Child is in Your Care-If any child leaves your care.
Earnings-If a child's earnings change. On your application you told us you expected total earnings for
to
. He or she (is) (is not) earning more than
be $
a month. He or she (is) (is not) performing
$
substantial services in self-employment.
a
Report at once if work pattern changes.
Criminal Offense-If any child is confined in a jail,
prison, penal institution or correctional facility due to a
conviction for a criminal offense.
School Attendancelf a child over age 18 stops attending
school full-time.
When a change occurs after you have begun receiving your annuity, you should report the change at once. You or
your representative can make your 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:
b
Railroad Retirement Board
Telephone Number:
If for some reason you cannot contact that office, you should contact:
b
U S RAILROAD RETIREMENT BOARD
844 N RUSH S T
CHICAGO IL 60611-2092
Page 13
Form AA-19 (05-04
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.
Ofice 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
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.
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,
andlor agencies listed below without your approval:
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) Information 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.
15) Professional Standard Review Organizations and State
Licensing Boards when services provided by physicians or
practitioners suggest unethical or unprofessional conduct.
1) An attorney, the Ofice of the President, a Congressional
ofice, a labor union or the Department of State's embassy or
consular ofices if they allege to be representing you at your
request.
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 Information
Management, Railroad Retirement Board, 844 North Rush
Street, Chicago, Illinois 6061 1-2092.
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.
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.
4) To people or organizations who are working for the RRB;
such information may include medical records.
Computer Matching and Privacy Protection Act Notice
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. Information 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.
5) The U.S. Treasury Department or U.S. Postal Service to
issue checks 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,
:arm AA-19 (05-04)
10) The General Accounting Ofice for audits and for collecting overpayments owed to the RRB or the Social Security
Administration.
Page 14
| File Type | application/pdf |
| File Modified | 2007-03-05 |
| File Created | 2007-03-05 |