AA-17 (proposed) Application for Widow(ers) Annuity

UNITED STATES OF AMERICA
DAIB o

n n n o c r l n c r r c r t r D n A D n

DO NOT WRITE IN THIS SPACE
OFFICIALLY FILED
MONTH
DAY
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OFFICE NUMBER

YEAR

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Application
for
Widow(er)'s Annuity

APPROVED

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1APPLICATION NUMBER

1

DATE CODED
MONTH

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DAY

YEAR

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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.
If filing for a widow(er)'s disability also complete Form AA-17b.
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 9 for this purpose. If
you do not know the answer to a question, print "unknown" in the space provided for the answer.
When entering dates, always use numbers. Also, be sure there is one number in each box. For example, you would enter February 12,
2001, as:
9
MONTH

012

DAY

YEAR

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 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
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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.
rc If the information is not correct, cross out the incorrect information and enter the correct information above it.
P-If the information is missina. fill it in.
Employee 1
Identification

EMPLOYEE'S NAME

-

2

EMPLOYEE'S SOCIAL SECURITY NUMBER

3

EMPLOYEE'S RAILROAD RETIREMENT CLAIM NUMBER

Applicant
4
Identification

APPLICANT'S NAME

5 a

6

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-.-

-

-

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STREET ADDRESS

-

b

CITY AND STATE

C

ZIP CODE

d

COUNTY

DAYTIME TELEPHONE NUMBER

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Form AA-17 (xx-xx) Destroy Prior Editions

-

1 If a railroad retirement survivor benefit was previously received by someone, go to Section 4; otherwise go to ltem 7.
Birth Date

7

Enter the employee's date of birth.

Month

1

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Day

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Year

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If the employee was age 62 or older when he or she died, go to ltem 9.
Disability

8 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. -*
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-

-

-

a

-

-

Yes
-

-

-

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.

II

9 Enter an " X in the appropriate box:
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The employee was in active m i l i l y service after September 7,1939. -

a Yes Go to Note and ltem 10
a No --+Go to ltem 12
-+

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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 ltem 83, the branch of the service
and the beginning and ending dates for each period of service.

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10 Enter an " X in 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 returning to the railroad.

-

a Yes
0

-+ Go toltem 11

No -+ Go to ltem 12
Yes

>

0

No

Regardless of whether 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 12a, the second in 12b,
and so on. Enter the date each job began and ended.

Recent

Employment

Name and Address of Employer
Name

Began

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Address

Month

/

Year

Ended

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Month

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Year

City, State, ZIP Code
Name

Ended

Began

Address

Month

Year

Month

Year

I City, State, ZIP Code

1
1

c Name

1

Address

1 City, State. ZIP Code
Enter an "X" in the appropriate box:
The employee was self-employed
during any of the last three calendar years.

SelfEmployment

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Month

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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.

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Page 2

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Year

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/

Ended
Month

a Yes Go to Item 14
a No Go to ltem 16
a Yes Go to ltem 15
a No Go to ltem 16
a This year
a Last year
a Year before last
-+

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-17 (xx-xx)

Began

-+
-+
-+

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Year

Railroad
Employment

Answer ltems 16 and 17 only if the employee was alive on October I,1981, and he or she had at least
25 years of railroad service; otherwise go to ltem 18.
If the employee was alive on October I,1981, and had at least 25 years of railroad service, read the section
"Requirements the Employee Must Have Met" in Part Iof the RB-I 7 booklet to find out what special conditions

Note: You may be requested to submit proof to verify the statements
made in ltems 16 and 17.

f

)

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

/ /

a

a

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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.

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
No

0
O

+ Go t o ltem 17
+ Go to ltem 18

Yes
No

Enter the requested information for each of the employee's marriages. Print the most recent marriage in 18a,
the second most recent in 18b, and so on.

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Name of Employee's
Wife or Husband
(if wife, include
maiden name)

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Date
Married

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

1

1

How Marriage
Ended
(check one)

Answer if Marriage Ended for Reason
Other than Employee's Death
City and State
Marriage Ended
(country if other
than United States

Date Marriage
Ended

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a

Death Month Day Year
0 Spouse's Death
Divorce
Annulment

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b

1

Death ~~~~h D~~ year

Month Day Year

u Spouse's Death
lvorce
Annulment
0 D.

C

0 Employee's Death Month Day Year
0 Spouse's Death

Month Day Year

u Divorce
u Annulment
Chi'dren

I Please read the section Definition OfA Child's Annuity" in Part 11 of the RB-17 booklet to find out what categories
of children may be eligible for a railroad retirement annuity.
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Enter an "X" in the appropriate box:
There are children who may be eligible
for a annuity.

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Yes

+ GO t o Item 20

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20 Enter the number of children who may be eligible for an annuity.

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Page 3

--*

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Form AA-17 (xx-m

1 a Yes

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

1

NO

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
a No

->

-+ Go to Item 22

+ Go to Section 4
-+ Go to ltem 23
-+ Go to Section 4

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

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1

Name of Parent
a

1

Date of Birth
Month

Address and Telephone Number

I -Year

Day

Telephone Number (include area code)

Month

Year

Day

1

(

Address

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Telephone Number (include area code)

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1

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Birth Date

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Information About The Applicant

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124 Enter your date of birth.
Enter your social security number.
(If none, enter "To be submitted.")

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Dav

Year

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~~~~~~~\~~

a Yes
a No

,

1

l

Month

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26 Enter an " X in the appropriate box:
I am now, or was previously, married to
someone other than the employee.

Marriages

-+

Go to ltem 27

-+ Go to ltem 29

( 27 1 Enter the requested information for each of your marriages to someone other than the employee.

( Print the most recent marriage in 27a, the second most recent in 27b, and so on.

1

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

a

1b

1

Address

1
b

1

Name

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Date
Married

Ended

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Date Marriage
Ended

a Spouse's Death Month

Day

Year

Year

a Spouse's Death Month

Dav

Year

Year

IJ Annulment
Spouse's Death Month Day
IJ Divorce
Annulment

Year

Month Day

Year

Month Dav

Month Day

IJDivorce
IJ Annulment
IJDivorce

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C Name

1

City and State
Married

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Name

1

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a

Marriage Ended
(country if
other than
United States)

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 the information requested in this item in Section 9 for each additional
unknown number.

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a Enter the name of the husband or wife
whose social security number is unknown. -b Enter that husband's or wife's date of birth.

/ c I Enter that husband's or wife's place of birth.
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Form AA-17 (xx-xx)

ltem 28 continues on the next page.
Page 4

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Month

Day

Year

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Marriages
[cont.)

1

1

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

- -

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e Enter that husbands or wife's mother's maiden name. ->

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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 Item 34. If "Yes," and you are female,
->
go
to Item 35.
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+Go to Item 30

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30 Enter the date you and the employee stopped living together.

Month

1

1

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Day

1

1

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Year

1

1

31 Enter the reason you and the employee
>

stopped living together.

Enter an " X in the appropriate box:
The employee was making regular contributions to my support when the
employee died. If "Yes," and you are male, go to ltem 34.
>
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.)

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Yes

a No +Go

to ltem 33

0
O

to Item 35

33 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.)

*

Yes +Go to ltem 35
NO +GO

Answer ltem 34 only if you are working or have ever worked in the railroad industry, and Items 29 or 32 was answered 'Yes

34 Enter an " X in the appropriate box:

Yes +Go to Note and ltem 35

The employee's contributions to me provided at least
one-half of the money needed to support me.

No +Go

to ltem 35

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Note: If answered "Yes, " complete and return to the RRB,
Form 6-134, Statement Regarding Contributions and Support.
35 Enter an " X in the appropriate box:
Within the past 12 months, I have been imprisoned or given a sentence
of confinement due to a conviction for a criminal offense.

Yes +Go to Item 36
No +Go to Section 5

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Month

36 Enter the date of the conviction.

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37 Enter the date of the sentence of confinement.

-

-

-

40 Enter the date confinement ended.

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Day

Year

Month

Day

Year

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Yes +Go to ltem 40

Month

Day

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Year

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Page 5

Year

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a No +Go to Section 5

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Month

O

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

Day

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38 Enter the date that confinement began. -

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Form AA-17 (xx-xx

Information About Applicant's Other Government Benefits
Public
Service
Pension

41 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

0 No

+ Go to ltem 44

ltem 42

(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.)

0 Yes + Go to Note and Item 44

42 Enter an " X in the appropriate box:
I amlwas an employee of the Federal Government.

* 0 No

+ Go to Item 43

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Note: If answered "Yes," complete and return to the RRB, Form G-208,
Public Service Pension Questionnaire, and verification of your pension.

Enter an " X in the appropriate box:
In my last 60 months 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.

0 Yes + Go to Item 44
No + Go to Note and Item 44

>

Note: If answered "No," complete and return to the RRB, Form G-208,
Public Service Pension Questionnaire, and verification of your pension.

'1

a Yes + Go to ltem 45

44 Enter an " X in the appropriate box:
I have filed, or plan to file, an application for benefts
under the Social Security Act.

Social
Security
Benefits

)

Q No + Go to ltem 48

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a Yes + Go to Item 46

45 Enter an " X in the appropriate box:
I have filed, or plan to file, for social security benefits
based on the record of someone other than myself.

->

No

+ Go to ltem 48

Yes

+ Go to Item 49
+ Go to Section 6

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46 Enter the name of the person on
>
whose account you are filing. -

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47 Enter that person's social security number.

Railroad
Retirement
Benefits

1 48

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Enter an "X. in the appropriate box:
I have filed, or plan to file within 90 days, an application for
monthly railroad retirement benefits based on the record of
someone other than the employee.

>

49 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.

'

,

-

a No
-

a Yes +Go to Section 6
>

0 No

+ Go to ltem 50

50 Enter the name of the person on whose
record you have filed or will file.

Enter that person's Railroad Retirement Board claim
number, including the letter prefix.
Form AA-17 (xx-xx)

Page 6

Prefix

>

If only six numbers,
enter here

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Information About Work And Earnings
Please read the section "How Earnings AffectAn Annuity" in Part V of the RB-17 booklet to find out how work and earnings
can affect your railroad retirement annuity. Also, please refer to Form G-77, How Earnings Affect Payment of Survivor
Annuities, for the exempt amounts to use when answering ltems 52 through 61.

'

Earnings
Last Year

If you were full retirement age or older when the employee died, or you are now full retirement age or older,
go to ltem 62.

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Answer ltems 52 through 55 only if you were age 60 or older last year and the employee died before January 1 of this year.

Wear)

1 52 1 Enter an "X" in the appropriate box:

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My total earnings for all employment last
year were more than the annual earnings
exempt amount shown on Form G-77.

a Yes +
a No +

-*

Go to ltem 53
Go to ltem 56

53 Enter your total earnings for last year.
(SHOW DOLLARS ONLY)

54 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.

a Yes + Go
a No +

to ltem 56
Go to ltem 55

-

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

Earnings
This Year

Answer ltems 56 through 59 only if you are age 60 or older, or will become age 60 this year.

1m I1 56 I Enter an "X" in the appropriate box:
I expect my total earnings for all employment
this year to be more than the annual earnings
exempt amount.

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57 Enter the total amount that you expect to eam this year.
(SHOW DOLLARS ONLY)

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a Yes +
a No +

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Go to Item 57
Go to ltem 60

+

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58 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
substantial services in self-employment in every
month this year.

0 Yes + Go to ltem 60

a No +

Go to ltem 59

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Page 7

Form AA-17 (xx-xx)

Earnings
This Year
(Cont.)

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 self-employment. -

Earnings
Next Year

Answer Items 60 and 61 only if you are returning this application in September, October, November,
or December and you are age 60 or older, or will become age 60 next year.

60 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.

0 Yes -+ Go to Item 61
0 No -,Go to Item 62

*

Enter the total amount that you expect to earn next year.

Railroad
Work

$

*

(SHOW DOLLARS ONLY)

Enter an "X" in the appropriate box:
I have worked for a railroad or other
employer in the railroad industry.

0 Yes -+ Go to ltem 63
0 No + Go to Section 7

Enter the name of your last railroad employer.

Enter the date you last worked for this employer.

*

Month

Day

Year

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Enter an "X" next to each month in this
year during which you worked, or you
expect to work, for an employer in the
railroad industry. -

Complete ltem 66 only if you expect your annuity to begin before January 1 of this year.

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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-orm AA-17 (xx-xx)

Page 8

Beginning Dates, Filing Dates, And Medicare
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Selecting a
Beginning
Date

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If you are under full retirement age on the date your annuity begins, your annuity will be reduced for early retirement.

67 Enter an " X in the appropriate box:
I want my annuity to begin on the earliest
date permitted by law, even if I will receive
a reduced annuity.

-

a .Yes -+Go to Item 69
No + Go to Item 68

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68 Since you do not want your annuity to begin on the
earliest date permitted by law, enter the date you want
your annuity to begin. -

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Month

Day

Year

1

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Note: If the date you select is more than 3 months affer you return
this application, you will need to file an updated application.
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.

69 Enter an "X" in the appropriate box:

Yes

I also want this application used to protect my
filing date for social security benefits.
Medicare

a No

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Please read the section ''Medicare Benefits" in Part Vlll of the RB-17 booklet for an explanation of the Medicare program.

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70 Enter an "Xuin the appropriate box:
I am enrolled in the Medicare Medical
lnsurance (Part B).

Yes + Go to ltem 71
No + Go to Item 73

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71 Enter the name of the agency where you have filed for ~edicare.->

72 Enter your Medicare claim number.

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Go to Section 8

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73 Enter an "X" in the appropriate box:
I am 64 years and 5 months of age or older.
74 Enter an " X in the appropriate box:
I wish to enroll in the Medicare Medical
lnsurance (Part B). -

1

-*

a No +

Go to Section 8

a Yes -+ Go to Item 75
-

75 Enter an " X in the appropriate box:
1 am claiming a special enrollment period
based on coverage by an employer group
health plan. -

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a No +

-

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Yes + Go to ltem 74

76 Enter an "X" in the appropriate box:
I am claiming premium surcharge relief based on
coverage by an employer group health plan.
Page 9

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Yes

O

No

Go to Section 8

Yes

+

a
Form AA-17 (xx-xx)

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 g o t o Section 9,
or call your financial institution for the information you need to complete Items 77-81. If you do not have a bank account, or
if you believe receiving your payments by Direct Deposit would cause you a hardship, g o t o Itern 82.

' F

Enter the name of your financial institution. - .

Deposit

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Direct

1 79

Enter the telephone number of your financial institution.

Area Code

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Tele~honeNumber

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*

Enter the routing transit number of your financial institution.

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Enter your account number.

a

Checking
0 Savings
G o t o Section 9

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

Check this box if you do not have a checking or
savings account, or if Direct Deposit would
cause you a hardship.
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Remarks
Remarks

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83 This section is to be used for the continuation of answersto 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-17 (xx-xx)

Page 10

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Certification
Enter an "X" 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 85
0 No -+Go to ltem 85

->
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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.
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.

1 /

I have received the booklet RB-17, SurvivorAnnuities, 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 l remarry;
If I begin to receive a pension from an agency of the Federal, state, or local government, or
if my present payments change;
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 I will 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.

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Signature
(First Name, Middle Initial,
Last Name)

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Month

Day

Year

Date
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If this certification is signed by mark ( " X ) in Item 85, 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)

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City, State, ZIP Code

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Area Code

*

~Bytirne~ e l e ~ h o nNumber
e

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Telephone Number
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b Signature of Witness

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Address (Number and Street)

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City, State, ZIP Code

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Area Code

Daytime Telephone Number
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Page 11

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Telephone Number
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Form AA-17 (xx-xx)

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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 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

*

ADDITIONAL FORMS YOU WERE ASKED TO COMPLETE

application, they will complete the blanks on the receipt and send it back to you. When i t 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. I f 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.

1

Form AA-17 (xx-xx)

Page 12

I

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EMPLOYEE'S NAME

APPLICANT'S NAME

RAILROADRETIREMENT BOARD C W M NUMBER DATE CLAIM RECEIVED

Your application for a railroad retirement widow(er)'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.

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

(are not) earning more than $
a month. You
(are) (are not) performing substantial services in selfemployment.
Report at once i f work pattern changes.

Social Security-If you file for social security
benefits based on any person's earnings record.

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

Address-If your address changes, even if your
payments are sent to a financial organization.

Widow(er) Is i n Your Care-If any person for
whom you are receiving an annuity dies or
leaves your care.

Remarriage-If

you remarry.

Earnings-If your earnings change. On your
application you told us you expected total
earnings for
to be $
. You (are)

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

Telephone Number:

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I

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

b

U S RAILROAD RETIREMENT BOARD
844 IV RUSH ST
CHICAGO IL 60611 -2092
Page I 3

Form AA-17 (xx-xx)

Paperwork Reduction Act and Privacy Act Notices
This notice is given under the Papenrvork 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.
1) The law which allows us to ask for the information;
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
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, 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.

Guarantee Corporation, 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.
8) The Internal Revenue Service or to state and local taxing
authorities for figuring your taxes and for use in audits,
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.
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.
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 27 to 47
minutes per response to complete, including the time for
reviewina the instructions. qettina the needed data, and
reviewing the completed fob. ~ederalagencies may not
conduct or sponsor, and respondents are not required to
respond to, a collection of information unless it displays a
valib 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 Resources Management,
Railroad Retirement Board, 844 North Rush Street,
Chicago, Illinois 6061 1-2092.

4) 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
Form AA-17 (xx-xx)

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
used to establish or verify a person's eligibility for
Federally funded or administered benefit programs
and for repayment of payments or delinquent debts
under these programs.

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