AA-17b (proposed) Application for Determination of Widow(ers) Disability

FORMAPPROVED

UNITED STATES OFAMERICA
RAILROAD RETIREMENT BOARD

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O.M.B. No. 3220-0030

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DO NOT WRITE IN THIS SPACE
OFFICIALLY FILED
MONTH
DAY

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APPLICATION FOR
DETERMINATION
OF WIDOW(ER)'S
DISABILITY

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YEAR

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OFFICE NUMBER

APPROVED

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DATE CODED
MONTH

APPLICATION NUMBER

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DAY

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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-17b, Widow(er)'s Disability Benefits, which explains information
you will need to answer many of the questions in this application.
Please read "Important Notices" on page 11 of this application.
Print all answers in ink or use a typewriter. If you need more space than is provided to answer a question, use Section 9 for this purpose. If
you do not know the answer to a question, print "unknown" in the space provided for the answer.
When entering dates, always use numbers. Also, be sure there is one number in each box. For example, you would enter December 13,
1998, as:
Month
Day
Year

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Some items in this application will not apply to you so you will not need to answer them. Based on your answer to a question, you may
be told to skip to another item number, or even another section. Follow the instructions that tell you to "Go to" another item. These are
designed to save you time and help you move through the application form quickly filling in only necessary information. If no "Go to"
instructions are given, answer the next item in order. Do not skip any items unless directed to do so.
If you are completing this application on behalf of someone else, you must answer each question as it applies to the applicant.

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Identifying Information
Check the information entered by the Railroad Retirement Board (RRB) for Items 1 through 6 for accuracy.
If the information is correct, go to Section 3.
If the information is not correct, cross out the incorrect information and enter the correct information above it.
If the information is missing, fill it in.

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Employee
Identification

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EMPLOYEE'S NAME

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2

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EMPLOYEES SOCIAL SECURITY NUMBER
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Applicant
Identification

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EMPLOYEE'S RAILROAD RETIREMENT CLAIM NUMBER

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APPLICANT'S NAME

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6

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ZIP CODE

d

COUNTY

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DAYTIME TELEPHONE NUMBER

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Form AA-17b

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Destroy Prior Editions

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Information About Your Medical Condition
Medical
Condition

7

Describe the medical condition(s) causing you to file. Enter the exact diagnosis if known and any secondary
condition.

When
Condition
Began

8

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

Year

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es

Q No

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+ Go to Item 10

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Go to ltem 12

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10 Enter an " X in the appropriate box:
Did your condition cause you to change:
Your job duties?
Your hours of work?
Your attendance?
Anything else about your work?

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Yes

No

Q If "Yes" to
any item, go
to Item 11

8

Q If "No" to

Q

Q

8

all items, go
toItem,,

1 11 I Explain what the changes in your work circumstances were, the dates they occurred, and why your condition I
I made these changes necessary.

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Changes in Work Circumstances

Dates
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When
Unable to
Work

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Why Your Condition Made Changes Necessary
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1

Day

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

l Work

Month

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1 Month 1

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

Day

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Year

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

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

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1 15 1 Enter the date you became able to work again.

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

F o r m AA-17b (%-k@

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P
Month

Medical
16 Enter an " X in the appropriate box:
Care or
I have received medical care or been examined for my
Examination
condition since the date in Item 8.
Treatment or 17
Testing

Q No

+
+

es

Page 2

Go to Section 4
Go to ltem 15

Day

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Year

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Q Yes + Gotoltem17
Q No + Go to Section 5
Q Yes + Go to Item 18
Q No + Go to Item 19

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Enter information about each hospital, institution, or clinic where you have received treatment or care
since the date in ltem 8.

Treatment or
Testing
(Continued)

a

Name of Facility

Address and ZIP Code

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

m

m

Telephone Number

Area Code

! Describe Type of Treatment or Testing

Dates Treated or Tested

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Name of Facility

Address and ZIP Code

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

a

Dates Treated or Tested

m

Area Code

Telephone Number

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! Describe Type of Treatment or Testing

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c Name of Facility

Address and ZIP Code

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

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

Doctor
Treatment
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m Yes
m No

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Go to ltem 20

-+

Go to ltem 21

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Page 3

Form AA-17b

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

Doctor
Treatment
(Continued)

Address and ZIP Code

Telephone Number

Area Code

Patient Number

! Describe Type of Treatment or Testing

Dates Treated or Examined

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Name of Physician

Address and ZIP Code

Area Code

Patient Number
Dates Treated or Examined

Telephone Number

1 Describe Type of Treatment or Testing
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Activity
Restriction

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

21

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22

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

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Go to Item 26

MONTH

YEAR

Describe the restriction.

24

Form AA-17b

Go to Item 22

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23 Enter the date the restriction began.

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a Yes
a No

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Activity
25
Restriction
(Continued)

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

26

Medication

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

a Yes
a IVo

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Go to Item 27

--, Go to Section 5

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

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I DOSAGE:(grams, number of pills,etc.) I FREQUENCY:
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Information About Your Education and Training
Schooling

28

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

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

--, Go to Item 30

a No

Go to ltem 33

a Yes

Go to ltem 32

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No

Go to ltem 33

Enter an " X in the appropriate box:
The certification or license I received is
currently in effect.

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Enter an " X in the appropriate box:
I have received specialized training.

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a Yes
a No
a Yes

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30

Describe the type of technical school you attended.

Enter an " X in the appropriate box:
I received a certification or license from
the technical school I attended.
32

I-] No

Go to ltem 33
Go to ltem 34

--, Go to Section 6

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34

--, Go to ltem 33

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

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TYPE

DATES

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Enter an " X in the appropriate box:
Have you used any of this training in your work?

a Yes
a No

Go to Item 36
Go to Section 6

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

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Form AA-I 7b ( m ~ ) '

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

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I EASY 1 HARD I

ACTIVITY

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EXPLANATION - Explain each "HARD answer.

Standing

0 l 0 l 0 l +

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Walking

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Eating

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o l o l o l +

Bathing
Dressing (Tying Shoes,
Combing Hair, Etc.)

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Other Bodily Needs

tl

tl

tl+

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Indoor Chores (Meal
Preparation, Laundry,
Cleaning, Etc.)
Outdoor Chores (Shopping,
Yardwork, Etc.)

1
1

Driving a Motor Vehicle
Using Public Transportation
Conducting Personal
Business (Talking to and
Dealing with Other People)

a a +
l o l o o l 0

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tl

Reading English (For
example, newspapers
and magazines)
Writing English (For example,
notes and letters)

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3-1 b
Work
Activities

a

a

a +

Enter any additional information that describes your daily activities.

Information About Your Work and Earnings
39 Enter an " X in the appropriate box:

Yes --, Go to Note and Item 40

Have you ever been employed
or self-employed?

+

a No

--, Go to Section 8

Note: If you answered "Yes" and you are a widow(etj filing for a disability annuity,
also complete and return to the RRB Form G-251, Vocational Report.

=arm AA-17b (Pe[l-w

Page 6

Work for an
Employer
Last
12 Months

40

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

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a Yes
a No

-e- Go t o Item 41
-e- Go t o ltem 43

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

FEBRUARY

MARCH

APRIL

MAY

JUNE

JULY

AUGUST

SEPTEMBER

OCTOBER

NOVEMBER

DECEMBER

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

Self43
Employment
Last
12 Months

44

45

Work Next
12 Months

46

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

JULY

AUGUST

SEPTEMBER

OCTOBER

NOVEMBER

DECEMBER

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

No

+ Go t o ltem 44

+ Go t o ltem 46

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

FEBRUARY

MARCH

APRIL

MAY

JUNE

JULY

AUGUST

SEPTEMBER

OCTOBER

NOVEMBER

DECEMBER

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

FEBRUARY

MARCH

APRIL

MAY

JUNE

JULY

AUGUST

SEPTEMBER

OCTOBER

NOVEMBER

DECEMBER

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

47

Enter the name and address of the
person or company for whom you
expect to work. (If self-employed,
enter "Self.")
>

48

Enter the date(s) you expect
to work. (For example, "June
and July," "Indefinitely Starting
9-96," etc.)

49

a Yes

>

a Yes
a No

+ Go t o Item 47
+ Go t o Section 8

>

Enter the gross amount you expect
to earn. (If you are self-employed,
enter the net amount.)
Page 7

Form AA-17b

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General Information
FilingAA-17
or AA-18

50

Social
Security
Benefits

51

52

I Service
Public

Enter an " X in the appropriate box:
I am filing either Form AA-17 or Form AA-18 at
this time.

>

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

>

tl Yes + Go to Item 56
tl No + Go to ltern 51
tl Yes + Go to ltem 52
tl No + Go to Item 53

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

Pension

54

Q Yes + Go to ltem 54

tl No

+ Go to ltem 56

a Yes + Go to Note and Item 56

1 amlwas an employee of the Federal Government.
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Note: If answered "Yes," also complete and return the RRB Form 6-208, Public
Service Pension Questionnaire, and verification of your pension.
Enter an " X in the appropriate box:
On my last day of employment, I was employed by a state or local
government or the military service and social security (FICA)
taxes were being deducted from my public service earnings.

Q Yes + Go to Item 56
tl No + Go to Note and ltem 56

( Note: Manswered
nNo,nalsocomplete and return the RRB Form
Public
Service Pension Questionnaire, and verification of your pension.
6-208,

Criminal
Offense

I 56 ( Enter an " X in the appropriate box:
Within the ~ a s 12
t months. I have been im~risonedor
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given
a
senience
I1 1 criminal offense. of confinement due to a conviction for a

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Enter the date of the conviction.

58

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

59

Enter the date of the sentence of confinement.

60

Enter the date that confinement began.

Enter an " X in the appropriate box:
Is your disability related to your confinement?
62

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

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+ Go to Item 57

Q Yes

1I tl No
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-

Month

+ Go to Section 9

II

Day

+

Year

tl Yes
tl No

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+

II

Month

Day

Year

Month

Day

Year

0 Yes

tl No
0 Yes + Go to ltem 63
No

+ Go to Section 9

1 Remarks
Remarks

This section is to be used for the continuation of answers to other items. Be sure to include the item
number at the beginning of the answer you wish to continue. You may also use this space to enter
any additional information that you feel may be important to include.

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

m Yes --, Go to Note and ltem 66
m No --, Go to Item 66

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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.

1 know that if I make a false or fraudulent statement in order to receive benefits from the RRB, or if I fail to dis,
close earnings or report employment of any kind to the RRB, I am committing a crime which is punishable
under Federal law.

66

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

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

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

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L-u-LLl

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

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a Signature of Witness

Address (Number and Street)
City, State, and ZIP Code
Telephone Number

Area Code

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Daytime Telephone Number

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Signature of Witness
Address (Number and Street)

II

City, State, and ZIP Code
Area Code

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Daytime Telephone Number
Form AA-17b

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Telephone Number

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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 12 of this
application. No matter which envelope you use, you must put the correct postage on the envelope. Be careful to provide enough postage, because your application and the accompanying forms may weigh more than a standard letter.
The U.S. Postal Service will not deliver your application unless it has the correct postage.
Make one final check before you seal the envelope to ensure that the following are enclosed:

*

NEEDED PROOFS

*
*

THE APPLICATION FORM ITSELF
ADDITIONAL FORMS YOU WERE ASKED TO COMPLETE

Note: Make no entries on page 12, which is the receipt for your claim. After the RRB receives your application,
they will complete the blanks on the receipt and send it back to you. When it is returned to you, you will know
that the RRB has received your application and has started the work needed to determine i f 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.

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

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

Page 11

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EMPLOYEE'S NAME

APPLICANT'S NAME

RAILROAD RETIREMENT BOARD CLAIM NUMBER

DATE CLAIM RECEIVED

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

1

a

Address - If your address changes.

a

Work - If I perform work for any employer, railroad or nonrailroad, or perform any self-employment work.

a

Remarriage - If you remarry.

a

Condition - If your condition improves.

a

Social Security - If you file for benefits on any person's earnings.

a *Criminal Offense - If you are confined in a jail, prison, penal institution, or correctional facility due to a conviction

for a criminal offense.
a

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

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

To report any of the above changes, contact:

1

5 3 Telephone Number:

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

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Form AA-I 7b

U S RAILROAD RETIREMENT BOARD
844 N RUSH ST
CHICAGO IL 60611-2092

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Page 12