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pdfUNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD
,
FORM APPROVED
O.M.B. No. 3220-0030
DO NOT WRITE IN THIS SPACE
OFFICIALLY FILED
DAY
MONTH
Application
for
Parent's Annuity
y,~
,oFFlc;NuM;ER
APPROVED
1
DATE CODED
APPLICATION NUMBER
7
I MONTH
DAY
YEAR
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CODED BY
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General Instructions
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 12 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 12,
2000, 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.
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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.
*
Employee 1
Identification
Applicant
Identification
EMPLOYEE'S NAME
>
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2
EMPLOYEE'S SOCIAL SECURITY NUMBER
3
EMPLOYEE'S RAILROAD RETIREMENT CLAIM NUMBER
4
APPLICANT'S NAME
5
a
STREET ADDRESS
b
CITYAND STATE
c
ZIP CODE
>
d
COUNTY
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1
1
1 1
6
-
--
+
>
-
DAYTIME TELEPHONE NUMBER
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1
Form AA-20 (04-04) Destroy Prior Editions
Information About The Employee
I 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.
Disability
-
9 Enter an "X" in the appropriate box:
Yes
The employee was unable to work at the time of death because of an
No
illness or accident which occurred at least five months before death.
Please read the section "Credit for Employee's Military Service" 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.
a
a Yes ---, Go to Note and ltem I 1
a No ---, Go to ltem 13
ote: If answered "Yes,"you will have to submit proof of the employee's milita
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.
Enter an "Xuin the appropriate box:
The employee had voluntary military service during the period
June 15, 1948, through December 15, 1950.
Enter an "X" in the appropriate box:
The employee had nonrailroad earnings after leaving the military
service and before returnina to the railroad.
>
a Yes --* Go to ltem 12
a No -> Go to ltem 13
0 Yes
>
a No
~ e ~ a r d l e of
s swhether the employee was retired at death, show the name and address of each railroad or nonrailroad employer for whom the employee performed any part-time or full-time work during the last 3 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.
Recent
Employmeni
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Name and Address of Employer
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Address
City, State, ZIP Code
1
1
b Name
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Began
Ended
Month
Year
Month
Year
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Began
Month
1
Year
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Ended
Month
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Year
City, State, ZIP Code
c
Name
Began
Address
Month
Year
Ended
Month
Year
City, State, ZIP Code
SelfEmployment
14 Enter an "X" in the appropriate box:
The employee was self-employed during any of the
last three calendar years.
>
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.
>
Form AA-20 (04-04)
Page 2
a Yes ---, Go to Item 15
a No -+ Go to ltem 17
a Yes ---, Go to Item 16
a No ---, Go to ltem 17
SelfEmploymeni
(Continued)
Enter an "X" in the appropriate box(es):
Show the year or years in which the employee's net
earnings from self-employment were more than $400.
This year
Last year
-
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 Item 19.
If the employee was alive on October 1, 1981, and had at least 25 years of railroad service, read the section
"Requirements The Employee Must Have Met" in Part I of the RB-17 booklet to find out what special conditions
Note: You may be requested to submit proof to verify the statements
made in ltems 17 and 18.
17 Enter an "X" in the appropriate box:
The employee "involuntarily and without fault":
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stopped working for his or her last railroad employer on or
after October I , 1975, o r
~Yes--,Gotoltem18
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.
No
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.
-1
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--* Go t o Section 4
Yes
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tl No
lnformation About The Employee's Family
Please read the section "Definition of a Widow(er)'sAnnuity" in Part I1 of the RB-17 booklet to find out what
categories of widow(er) may be eligible for a railroad retirement annuity.
-
19 Enter an "X" in the appropriate box:
There is a widow(er), remarried widow(er), or surviviqg divorced
spouse who may be eligible for a widow(er)'s annuity.
Children
Yes
Q No
Please read the section "Definitionof a Child's Annuity" in Part I1 of the RB-17 booklet to find out what categories
of children may be eligible for a railroad retirement annuity.
20 Enter an "X" in the appropriate box:
There are children who may be eligible for an annuity.
+
Q Yes
Q No
I Answer Item 21 only if the employee was male.
1
Enter an "X" in the appropriate box:
A child of the employee is expected to be born.
Q Yes
Q No
lnformation About The Applicant
Relationship 23 Enter an "X" in the appropriate box:
Q Yes
I am the employee's only living natural parent,
stepparent, or adoptive parent.
Enter an "X" in one box only to show your
relationship to the employee.
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Q No
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Q Natural Parent
--, Go t o Item 29
Stepparent
--, Go t o Item 25
Q Adoptive Parent + Go to Item 26
Page 3
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Form AA-20 (04-04)
StepParent
25 Enter the date of your marriage to the employee's
natural mother or father.
Adoptive
Parent
26 Enter the place (city and state or foreign country)
where you adopted the employee.
-
1 1
1 1 1 1
MOI-I~~I
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;D
Ya
;r
Go to ltem 29
27 Enter the date of the adoption.
Enter the name of the court which issued the
adoption decree.
Support
>
Enter an "X in the appropriate box:
The employee was contributing at least one-half of the money and
goods needed to support me at the time the employee died or at
the beginning of the employee's period of disability if he or she
had one. (Consider the following as contributions to support:
money, food, clothes, paying bills, providing rent-free housing.)
Yes
--*Go to Note and ltem 30
Q No -> Go to Section 11
Note: If answered "Yes," you will have to complete and return to the RRB,
Form G-134, Statement Regarding Contributions and Support.
Marriage
m Yes + Go to ltem 31
m No --> Go to ltem 32
30 Enter an " X in the appropriate box:
I remarried after the employee's death.
31 Enter the requested information for each of your marriages after the employee's death. Print the most recent
marriage in a, the second most recent in b, and so on.
How Marriage Ended
(Check One)
Date
Married
Your Husband's or
Wife's Name
a
Month
Day
(If Marriage Never Ended
Leave Blank)
Spouse's death
Year
Divorce
Q Annulment
b
Month
c
Month
1
-
Social
Security
N~~mhnr
Criminal
Offense
32 Enter your social security number.
~fnone enter "TO BE SCIBMITTED."
-
Enter an " X in the appropriate box:
Wahin the past 12 months, I have been imprisoned or given a sentence
of confinement due to a conviction for a criminal offense.
Form AA-20 (04-04)
Page 4
Day
Day
Year
Year
1
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m
m
m
m
m
0
Spouse's death
Divorce
Annulment
Spouse's death
Divorce
Annulment
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m Yes --,Go to ltem 34
No --, Go to Section 6
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m Yes --,Go to Item 38
m No -> Go to Section 6
Enter an "X" in the appropriate box:
Has the confinement ended? --
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Social
Security
Benefits
39 Enter an "X"in the appropriate box:
I have filed, or plan to file, an application for benefits
under the Social Security Act.
*
-
Enter an "X" in the appropriate box:
I have filed, or plan to file, for social security benefits based on
someone other than myself. -
1 1
Enter the name of the person on whose account
you are filirlg.
-
m Yes --*Go to ltem 40
m No --,Go t o ltem 43
m Yes -> Go to ltem 41
m No --,Go t o ltem 43
>
>
*
42 Enter that person's social security number.
I
Railroad
43 Enter an "X" in the appropriate box:
Retirement
I have filed, or plan to file within 90 days, an application for
Benefits
m No
>
-
Enter an "X" in the appropriate box:
I have filed, or plan to file, an application for railroad retirement
benefits based on my own railroad employment.
-1
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Yes --,Go t o ltem 44
monthly railroad retirement benefits based on someone other
than the employee.
Enter the name of the person on whose record
you have filed or will file. ---
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--,Go t o Section 7
Yes --,Go t o Section 7
Q No --,Go to ltem 45
>
PrefixEnter that person's Railroad Retirement Board
claim number, including the letter prefix. ----------------->
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If only six numbers, enter here
II
T-ri-7-
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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.
I If you were age 70 or older when the employee died, or you are now age 71 or older, go to ltem 58, Railroad Work.
When answering ltems 47 through 57, refer to Form G-77, How the Amount o f Earnings Affects Payment o f Survivor
Annuities, for the exempt amount to use.
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If the employee died January 1 or later of this year, skip ltems 47-50 and go to ltem 51, Earnings This Year.
Earnings
Last Year
(Year)
Enter an "X" in the appropriate box:
My total earnings f o r all employment last year
were more than the annual earnings exempt
amount shown on Form G-77. -
>
m Yes -* Go to ltem 48
m +Go to ltem 51
Enter your total earnings for last year.
>
(SHOW DOLLARS ONLY)
Enter an "X" in the appropriate box:
I earned more than the monthly earnings exempt amount
in employment for hire or performed substantial services
in self-employment in every month last year.
Page 5
>
-
m Yes --,Go to ltem 51
m No
Go to ltem 50
Form AA-20 (04-04)
I ~ J A N I ~ = ~ ~
Earnings
50 Enter an " X next to each month last year in which you did
Last Year
not earn more than the monthlv earnings e x e m ~amount
t
(Continued)
1
Earnings
This Year
or perform substantial service; in self-&nployment.
51 Enter an "Xin the appropriate box:
I expect my total earnings for all employment this year to be
more than the annual earnings exempt amount.
Go to ltem 52
a Yes
Go to ltem 55
(Year)
52 Enter the total amount that you expect to earn this year.
(SHOW DOLLARS ONLY)
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53 Enter an " X in the appropriate box:
I expect to earn more than the monthly earnings exempt
amount in employment for hire, or to perform iubstantkl
services in self-employment in every month this year.
-
a Yes -*
a No
Go to ltem 55
No --> Go to Item 54
>
54 Enter an " X next to each month this year in which you did
not, or do not expect to, earn more than the monthly earnings exempt amount or perform substantial services in
Earnings
Next Year
Enter an " X in the appropriate box:
I am returning this application in September, October,
November, or December.
-
>
-
(Year)
a Yes -*
a No
a Yes -*
-
Enter an "X" in the appropriate box:
I expect my total earnings for all employment next year to be
more than this year's annual earnings exempt amount.
a No
---
58 Enter an "X" in the appropriate box:
I have worked for a railroad or other employer in the
railroad industry.
1
1
59 Enter the name of your last railroad employer.
-
-
a Yes
a No ->
>
61 Enter an "Xnext to each month in this year during which
. you worked, or you expect to work, for an employer in the
railroad industry.
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I Complete ltem 62 only if you expect your annuity to begin before January 1 of this year.
II II
62 Enter an "X" next to each month of last year
during which you worked for an employer in
the railroad industry
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Form AA-20 (04-04)
Go to ltem 58
Go to ltem 57
Go to Item 58
.
Enter the total amount that you expect to earn next year.
(SHOW DOLLARS ONLY)
Railroad
Work
-*
Go to Item 56
Page 6
Go to ltem 59
Go to Section 8
-1
Filing Date And Medicare
I Filing
Answer Item 63 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.
Protecti0n
a Yes
a No
63 Enter an "X" in the appropriate box:
I also want this application used to protect my filing date for
social security benefits.
Medicare
>
Please read the section "Medicare Benefits" in Part Vlll of the RB-17 booklet for an explanation of the
Medicare program.
I
a Yes
a No
I
Enter an "X" in the appropriate box:
I am enrolled in the Medicare medical insurance (Part B). -------+
+ Go to ltem 65
-
Go to ltem 67
Enter the name of the agency where you have filed for Medicare. ---->
66 Enter your Medicare claim number.
>
1
1
Enter an "Xuin the appropriate box:
I am 64 years and 5 months of age or older.
Enter an "X" in the appropriate box:
I wish to enroll in Part B.
+
Enter an "X" in the appropriate box:
I am claiming a special enrollment period based on coverage
by an employer group health plan.
>
Enter an "X" in the appropriate box:
I am claiming premium surcharge relief based on coverage by
an employer group health plan.
-
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a Yes
a No
a Yes
a No
a Yes
a No
Go To Section 9
-
Go to ltem 68
+ Go to Section 9
-
Go to ltem 69
+
Go to Section 9
D Yes
>
a No
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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 71-75. If you do not have a bank account, or
receiving your payments by Direct Deposit would cause you a hardship, go to ltem 76.
Direct
Deposit
Enter the name of your financial institution.
AI
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72 Enter the telephone number
for your financial institution.
Area Code
*
1
Enter the routing transit number of your
financial institution.
74 Enter your account number.
Telephone Number
1
* I I I I I I I I I
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Enter an "X" in the appropriate box:
Type of account for the above account number.
>
a Checking
a Savings
Go to Section 10
Check this box if you do not have a checking
or savings account, or if Direct Deposit would
cause you a hardship.
Page 7
>
Form AA-20 (04-04)
Remarks
l3emarks
77 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.
Form AA-20 (04-04)
Page 8
1
Certification
a Yes
a No ->
Enter an "X" in the appropriate box:
--t
I will have a guardian or other representative sign
this application on my behalf.
f
(
Go to Note and ltem 79
Go to Item 79
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.
I 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, SuwivorAnnuities, and the booklet RB-Ss, Events ThatAffect A
SuwivorAnnuity. 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 marry;
If I file for social security benefits based on any person's earnings record;
If I go to work for an employer in the railroad industry;
If Iwill earn more than the annual earnings exempt amount, and it was not reported on the application;
If I reported expected earnings and my earnings estimate changes;
If my address changes;
If any person for whom I am receiving benefits dies or leaves my care;
If I am 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)
I I
80
w
If this certification is signed by mark ("X") in ltem 79,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
1 I
Daytime Telephone Number
b Signature of Witness
1
-1
1
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Telephone Number
1
Address (Number and Street)
City, State, and ZIP Code
1 I
>
Daytime Telephone Number
Page 9
Area Code
II
Telephone Number
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Form AA-20 (04-04)
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.
,
*
I1
1
.
*
*
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 11 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 APPI-ICATION FORM ITSELF
ADDITIONAL FORMS YOU WERE ASKED TO COMPLETE
i
Note: Make no entries on page 11, 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-20 (04-04)
Page 10
EMPLOYEE'S NAME
APPLICANT'S NAME
RAILROAD RETIREMENT BOARD CLAIM NUMBER
DATE CLAIM RECEIVED
Your application for a railroad retirement parent's annuity has been received and will be processed as quickly as possible. If
, you should contact the servicing field ofice shown below. If
you do not receive your first payment by
you change your address, or if there is some other change that may affect your claim, you or your representativeshould
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.
a
,
Work-If you go to work for an employer in the railroad industry.
Marriage-If you marry.
Social Security-If you file for social security benefits based on any person's earnings record.
Earnings-If your earnings change. On your application you told us you expected total earnings for
. You (are) (are not) earning more
to be $
than $
a month. You (are) (are not) performing substantial services in self-employment.
a
Address-If your address changes, even if your payments are sent to a financial organization.
Parent Is In Your Care-If any person for whom you
are receiving an annuity dies or leaves your care.
a
Report at once if work pattern changes.
Criminal Offense-If you are confined in a jail,
prison, penal institution, or correctional facility due
to a conviction for a criminal offense.
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:
b Railroad Retirement Board
'BP Telephone Number:
If for some reason you cannot contact that office, you should contact:
b U S RAILROAD RETIREMENT BOARD
844 N RUSH ST
CHICAGO lL 60611-2092
Page 11
Form AA-20 (04-04
Paperwork Reduction and Privacy Act Notice
This notice is given under the Paperwork ReductionAct 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.
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;
3) the reason why the information is requested; and
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.
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 RetirementAct 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-unableto
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:
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.
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.
11) The
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.
15) Professional Standard Review Organizations and State
Licensing Boards when services provided by physicians or
practitioners suggest unethical or unprofessional conduct.
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 606112092.
Computer Matching and Privacy Protection Act Notice
4) People or organizations who are working for the RRB;
such information may include medical records.
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.
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. ~hese-matchingprograms 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
.~avmentsor delinauent debts under these .programs.
<
7) The Social Security Administration, Centers for
Medicare & Medicaid Services, Pension Benefit
Guarantee Corporation, Office of Personnel Management,
Form AA-20 (04-04)
Page 12
| File Type | application/pdf |
| File Modified | 2007-03-05 |
| File Created | 2007-03-05 |