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

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XXXXXXXXXX

Proposed

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

FORM APPROVED

O.M.B. No. 3220-0030
DO NOT WRITE IN THIS SPACE

OFFICIALLY FILED
MONTH

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

DAY

YFAR

APPROVED

DATE CODED

APPLICATION NUMBER

Before you complete this application, be sure to read Part I of booklet RB-17, Survivor Annuities, which explains information you

will need to answer many of the questions in this application.

Please read "Important Notices" on page 16 of this application.

Print all answers in ink or use a typewriter. If you need more space than is provided to answer a question, use Section 10 for this

purpose. If you do not know the answer to a question, print "unknown" in the space provided for the answer.

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:
MONTH
DAY
YEAR

012

112 2101011

Some items in this application will not apply to you so you will not need to answer them. Based on your answer to a question,
you may be told to skip to another item number, or even another section. Follow the instructions that tell you to "Go to" another
item. These are designed to save you time and help you move through the application form quickly, tilling 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.

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, till it in.

1 1 1 EMPLOYEE'S NAME

-

I

1 2 ( EMPLOYEE'S SOCIAL SECURITY NUMBER

1 1

I

3 EMPLOYEE'S RAILROAD RETIREMENT CLAIM NUMBER

Applicant
4
Identification

APPLICANT'S NAME

I

-I

1

1
-

CITYANDSTATE

c

ZIP CODE

d

I

I

COUNTY

7

I

DAYTIME TELEPHONE NUMBER

6
J

-

b

I

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Form AA-18 (fig-@ Destroy Prior Editions

Information About The Employee

I If a railroad retirement survivor benefit was previously received by someone, go to Section 4; otherwise go to Item 7.

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Residence

1

1

8 Enter the state (or country if other thaq United States) which was the
+I
employee's permanent home at the time of death.
If the employee was age 62 or older when he or she died, go to Item 10.

Disability

9 Enter an "X" in the appropriate box:
The employee was unable to work at the time of death because of an
illness or accident which occurred at least five months before death. +

Military
Service

Please read the section "Credit for Employee's Military Servicel'in Part V of the RB-17 booklet to find out
how active military service is determined.

Yes
No

0

10 Enter an "X" in the appropriate box:
The employee was in active militaty service after September 7,1939. -----+

Yes + Go to Note and Item 11
No + Go to Item 13

I

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

I I

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

Yes + Go to ltem 12
No + Go to Item 13

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

O

a

>

Yes
No

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

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

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Name and Address of Employer

I

a Name

Ended

Began

Address

Month

Year

Month

Year

City, State, ZIP Code
b Name

Began

Address

Month

Ended

Year

Month

Year

City. State, ZIP Code
c Name

Began

Address

Month'

Year

Month

Year

I

I

I

I

City, State, ZIP Code

Employment
Iself-

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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.
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Form AA-18

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Page 2

Ended

Yes + Gotoltem15
No + G o t o l t e m l 7
Yes

+ Gotoltem16
Iteml7
I

This year

Self16 Enter an "X" in the appropriate box(es):
Employment
Show the year or years in which the employee's net
earnings from self-employment were more than $400.
Con't

I I
Railroad
Employment

IJ

Last year

a Year before last

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

1 If the employee was alive on October 1, 1981, and had at least 25 years of railroad service, please read the
section "Requiremenfsfhe Employee Musf Have Mef" in Part I of the RB-17 booklet to find out what special
conditions may apply.
Note: You may be requesfed fo submit proof to verify the sfafemenfs
made in lfems 17 and 18.
17 Enter an 'X' in the appropriate box:
The employee "involuntarily and without fault":

I

1

a

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

1

-

18 Enter an "X" in the appropriate box:
The employee declined an offer from a railroad employer to return
to a job in the same 'class or craft" as his or her last railroad job.

I

I
Yes
No

+ Go to ltem 18
+ Go to ltem 19

Yes

O

No

Employee's 19 Enter the requested information for each of the employee's marriages. Enter the most recent marriage in 19a,
Marriages
the second most recent in 19b, and so on.
Answer if Marriage Ended for Reason
Other than Employee's Death
Name of Employee's Wife
or Husband
(if wife, include
maiden name)

a

b

C

Nidow(er)

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

Date
Married
Month Day

Year

Month Day

Year

Month Day

Year

How Marriage
Ended
(check one)

0 Employee'sDeath
0 Spouse's Death
0 D'lvorce
0 Annulment
0
Death
0 Spouse's Death
0 D'lvorce
0 Annulment

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

Date Marriage
Ended
Month Day

Year

Month D~~ year

0 Employee's Death Month
0 Spouse's Death
0 D'lvorce
0 Annulment

Day

Year

Answer Item 20 only if you and the employee were divorced.
Please read the marriage requirements in Part I11 of the RB-17 booklet to find out what categories of
widow(er)s may be eligible for a railroad retirement annuity.
20 Enter an "X" in the appropriate box:
'There is a widow(er) or remarried widow(er) who may be eligible
for a widow(er)'s annuity.
Page 3

>

O
O

Yes
No

(H-M

Form AA-18

1 !
parents

I

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

a Yes +Go to Item 22
a No +Go to Section 4
a Yes +Go to ltem 23
a No +Go to Section 4

*

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

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

I Date of Birth (
Address and Telephone Number
I Month 1 Day I Year lAddress

Name of Parent
a

I

I

I

I

b

Month

Telephone Number (include area code)
(
1
Address

Year
Day -

Telephone Number (include area code)

I

1

Bitth Date

Security
Number
Mariages

24 Enter your date of birth.

*

25 Enter your social security number.
(If none, enter "To be submitted.")

+

I

Moyth

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

i

D y

i

Ygar

II

0
0

Yes
No

I

II
I

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+ Go to ltem 27
+ Go to Item 29

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

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

a

Name

I

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I

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I

I

I

I

I

C Name

I

Date
Married
Month Day

Year

Month Day

Year

Month Day

Year

How Marriage
Ended
(check one)

I I

I

I

I

Day

Year

0 Spouse's Death Month
0 Divorce

Day

Year

0 Spouse's Death Month
0 Divorce

Day

Year

0Divorce

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

a Annulment

a Annulment

I

I

Date Marriage
Ended

0 Spouse's Death Month

I

I

-bName

If Marriage Never Ended, Leave These Blank

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

Annulment

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

I

I c Enter that husband's or wife's place of birth.

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Item 28 continues on the next page.

Form AA-18

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Page 4

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Marriages

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

-

e Enter that husband's or wife's mother's maiden name. -,

(

"ppon

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If you and the employee were divorced, go to Item 35.

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

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31 Enter the reason you and the employee
stopped living together.

Enter an 'X" in the appropriate box:
The employee was under a court order to contn'bute to my
SUPPOh
(Note: Answer Yes" if there was a court order, even if
the employee was not obeying it.)
One-Half
Support

I

No +Go

to ltem 30

l

0
0

Yes
No +Go to ltem 33

Yes +Go to ltem 35

>

NO

+GO

to ltem 35

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

/
\
Criminal
Offense

Yes

>

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.)

'

0
0

0

Yes +Go to Note and ltem 35
NO

>

+GO

to ltem 35

Note: If answered "Yes, " complete and return to the RRB,
\
Form 6-134. Statement Reaardina Contributions and S u ~ ~ o r t .

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.

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

>

Page 5

0
0

0
0

Yes +Go to ltem 36
No +Go

to Section 5

Yes +Go to ltem 40
No +Go to Section 5

Form AA-18

(fl#$&

1

1

Information About Children

I

Please read the section "Definition o f a Child's Annuity" in the RB-17 booklet to find out what categories of children may
be eligible for a railroad retirement annuity.
Children

1

41 Print the requested information for every child for whom you are filing this application who may be entitled
to a child's annuity. Print the youngest child in a, the second youngest in b, and so on. Always complete f.
If a child does not have a social security number, enter "TO BE SUBMITTED."
Child's Full Name and
Social Security Number

'

a Name
I

I

I

;

Relationship to Employee
(Check One)
Date of Birth
..
[Na ural]
O Adopted
Year
Month
Day
Stepchild
Grandchild
1
Other

a+-

a

b Name

0
CI

I
I

I

/

I
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/

I

I

I

I

I

I

I

I

I

I
I

I
I

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I

e Name
I

1
Children
Not Living
With
Applicant

1

Legal
Guardian

Month

Day

Year

I

I

I

Day

Year

keg4hak [Natlrral]
Adopted
Month
0 Stepchild
Grandchild
Other

I

I

I

I

I

I

I

Yes

O

No

m Yes
O

No

0 Yes
O No

0 k g t h w a k [Natllral]
O Adopted
Month
I

f

l

Adopted
Stepchild
0 Grandchild
0 Other

a

c Name

I d Name

I

4egMwte [Natural]

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

Day

Stepchild
0 Grandchild
Other

Yes

Year

O

a

4ay4mab [Natlrral]
Adopted
Month
0 Stepchild
IJ
Grandchild
Other

Day

Year
I

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

No

0 Yes
O

No
Yes
No

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

I

First Name
of Child

I

Person with Whom Child now Lives
Child's Address

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

Form AA-18 (PI&$,@

Page 6

Name

-

Relationship to Child

Yes +Go t o ltem 44

O

No +Go t o ltem 45

1

Legal
Guardian
Con't

Manied
Children

44 Print the requested information for every child in ltem 41 who has a court-appointed legal guardian.

q
First Name of Child

Name and Address of Guardian

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

>

a Yes+ Go to ltem 46
a No +Go to ltem 47
1

46 Print the requested information for every child in Item 41 who has ever been married.
Print the youngest child in 46a, etc.
Enter an "X" in the

Child's
Married Name

Date Married

a

Month

b

Month

II

I
GrandChildren,
Other
Children

Appropriate Box:

The Child Is Still Married

Day

Year

1

I

II

Day

Year

I

I

a
a

Yes

Yes

0 No
0 No

Date Marriage Ended

if Child Is Not

Still Married

Month

Day

II

Year

II

II

Month

Day

Year

I

I

I

I

If %gttm&& rNatural%r "Adopted" was checked for every child in Item 41, go to Item 49.

0
0

47 Enter an " X in the appropriate box:
Every "Grandchild" or "Other Child" in ltem 41 was living
with the employee at the time the employee died.

Yes +Go to Item 49
No +Go to ltem 48

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

First Name

of Child

Children
For Whom
You Are
Not Filing

Name

1

Address

49 Enter an "X" in the appropriate box:
There is a child for whom I am not filing this
application who may be entitled to a child's annuity. -

0
0

Relationship to Child

Yes -+ Go to ltem 50
No +Go to ltem 51

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

Child's Full Name

1

Reason for Not Filing

I

Page 7

Form AAd 8

(@-d

Information About Applicant's Other Government Benefits
I

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51 Enter an " X in the appropriate box:

I am receiving or expect to receive a
pension\or I have
received or expect to receive a lump-sum payment
instead of a pension, based on my earnings,-from an
agency of the Federal, state, or local government.

Pension

1

I

(

I
I

(Answer "Non 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 lumpsum payment

that was just your contributions to the pension fund

plus interest.)

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

0 Yes +Go to ltem 52
0 No +Go to ltem 54

1

0 Yes +Go to Note and ltem 54
0 No +Go to ltem 53

I

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Note: If answered "Yes, " complete and return to the RRB, Form 6-208,
Public Service Pension Questionnaire, and verification of your pension.

I

1

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( 53 Enter an "X" in the appropriate box:

I

-

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.

0 Yes + Go to ltem 54

a No

I

+ Go to Note and ltem 54

t

ote: I f answered "No," complete and return to the RRB, Form 6-208,
Public Service Pension Questionnaire, and verification of your pension.
Social
Security
BenefitsFiled For

a Yes +Go to ltem 55
a No +Go to Item 56

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

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

Social
Security
BenefitsFuture
Filing

Social Security Number
Filed On

Person Whose
Record Was Filed On

a Yes +Go to ltem 57
a No Go to Item 59

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

-

+

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

58 Enter that person's social security number.

(p

>

I I I I I I

Form
AA-18
-f641)
@

Railroad

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

Benefits

-

-+ Go to Item 60

0 No

-+ Go to Section 7

a Yes -+ Go to Item 61

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

-

a Yes
0 No

-+ Go to Section 7

61 Enter the name of the person on whose record the

application has been or will be filed.

1

If only six numbers,
enter here

Prefix

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

w

Information About Work And Earnings
Please read the section "How Earnings Affect An Annuity" in Part V of the RB-17 booklet to find out how work and earnings
can affect your railroad retirement annuity or a child's annuity. Also, please refer to Form 6-77, How Earnings Affect
Payment of Survivor Annuities, for the exempt amounts to use when answering ltems 63 through 69. When answering
ltems 63 through 71, consider only yourself and the children listed in ltem 41.

1

Earnings
Last Year

Answer ltems 63 and 64 only if the employee died before January 1 of this year.
63 Enter an " X in the appropriate box:
My total earnings, or the total earnings of a child, for all
employment last year were more than the annual earnings
e x e m ~amount
t
shown on Form G-77.

(Year)

0 Yes -+ Go to Item 64
0 No
Go to Item 65
-+

64 Print the requested information for every family member whose total earnings for last year were more than the
annual earnings exempt amount shown on Form G-77. Use as many lines as needed beginning with 64a.
2 Total Earnings for Last Year
(Show Dollars Only)

a 1 Family Member

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

which the family member did not earn more than

the monthly earnings exempt amount or perform

substantial services in self-employment.

CI Yes
CI No

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

b 1 Family Member

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

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

-

-

CI Yes
CI No

~

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Page 9

F o r m AA-18

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

c 1 Family Member

Earnings
Last Year
Con't

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

(Year)

1

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

O Yes
O No

IIJANI)~~~

~JULrTiqrTiqrTiz

65 Enter an "X" in the appropriate box:

Yes + Go to Item 66
I expect my total earnings, or the total earnings of a child

for all employment this year to be more than the annual +
NO + GO to Item 67
earnings exempt amount.
66 Enter the requested information for every family member whose total earnings for this year are expected to
be more than the annual earnings exempt amount. Use as many lines as needed beginning with 66a.
a 1 Family Member
2 Total Expected Earnings for This Year
(Show Dollars Only)

a

Earnings

This Year

(Year)

1

I

3 Enter an "X" in the appropriate box:

The family member expects to earn more than the monthly earnings

exempt amount in employment for hire or to perform substantial

services in self-employment in every month this year.
4 Enter an "X" next to each month this year in which the

family member did not, or does not expect to, earn

more than the monthly earnings exempt amount or

perform substantial services in self-employment.

( b 1 Family Member

+

O Yes

O No

rTliq~JUL~~rTiGil~1

I

2 Total Earnings for This Year
(Show Dollars Only)

I

3 Enter an "X" in the appropriate box:

a Yes

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

I
(
J
A
N
I
m
l
F
1
m
m
m
l

I

c 1 Family Member

3 Enter an " X in the appropriate box:

The family member expects to earn more than the monthly earnings

exempt amount in employment for hire or to perform substantial

services in self-employment in every month this year.

(

I

>

O No

2 Total Earnings for This Year
(Show Dollars Only)

*

Ll Yes

Ll No

4 Enter an X next to each month this year in which the

family member did not, or does not expect to,
eam
more than the monthly earnings exempt amount or

perform substantial services in self-employment.

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

Form AA-18

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Page 10

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Earnings
Next Year
(Year)

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

*

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

a Yes + Go to Item 68
a No +Go to ltem 70
a Yes + Go to Item 69
a No + Go to Item 70

1 69 Enter the requested information for every family
memberwhose total earnings for next year are expected to be I
more than the annual earnings exempt amount. Use as many blanks as are needed beginning with 69a.
Expected Earnings
Expected Earnings
Expected Earnings
Family
Family
Family
for Next Year
for Next Year
for Next Year
Member
Member
Member
(Show Dollars Only)
(Show Dollars Only)
(Show Dollars Only)

Railroad
Work
I

a
a

70 Enter an "X" in the appropriate box:
Yes + Go to ltem 71
I have worked, or a child has worked, for a railroad'
No + Go to Section 8
or other employer in the railroad industry.
71 Enter the requested information for every family member who has worked for a railroad or other employer
in the railroad industry. Use as many lines as needed beginning with 71a.
3 Date Last Worked
a 1 Family Member
2 Railroad Employer
Month 1 Day I Year
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rn

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

-

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

3 Date Last Worked

2 Railroad Employer

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

rn

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* ~

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

l

c 1 Family Member

2 Railroad Employer

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A

N

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3 Date Last Worked

4 Enter an "X" next to each month in this year during

which the family member worked for an employer in

>
the railroad industry.

5 If you expect the annuity to begin before January 1
of this year, enter an " X next to each month of last
year during which the family member worked for an
employer in the railroad industry.
>
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Page 11

Form AA-18 (R-m

Filing
Protection

Answer only if you are age 62 or older, disabled, or otherwise eligible for social security old age, disability,
or survivor benefits and you have not filed an application for such benefits.
72 Enter an "X" in the appropriate box:
I also want this application used to protect my
filina date for social securitv benefits.

O Yes
O No

>

Benefits are generally paid by Direct Deposit to your bank, savings and loan, credit union, or other financial institution. To
provide the information we need to correctly deposit your payments, attach a voided personal check and go to Section 10,
or call your financial institution for the information you need to complete Items 73-77. If you do not have a bank account, or
receiving your payments by Direct Deposit would cause you a hardship go t o Item 78.

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Direct
Deposit

73 Enter the name of your financial institution.

+

74 Enter the telephone number of your financial institution.

-

AREA CODE

TELEPHONE NUMBER

I I

I I I I I I

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

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

+

aChecking
aSavings
Go to Section 10

-1
Remarks

Form AA-18

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

>

Remarks
79 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.

(&-w

Page I 2

Certification
Certification

a Yes + Gd to Note and Item 81
a No + Go to ltem 81

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

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.
81 1 know that if I make a false or fraudulent statement in order to receive benefits from the Railroad
Retirement Board (RRB), I am committing a crime which is punishable under Federal law.

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

I

(
1
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,\

(

I agree to immediately notify the RRB:
If 1 marry;
If I begin to receive a pension from an agency of the Federal, state, or local government, or if my
present payments change;
If an application is filed for social security benefits for me or any child based on any person's earnings record;
If I or any child go to work for an employer in the railroad industry;
If I or any child will earn more than the annual earnings exempt amount, and it was not reported on the
application;
If I reported expected earnings for myself or any child and that earnings estimate changes;

If my address changes;
If any child for whom I am receiving benefits dies, marries, or leaves my care;
If I am, or any child is, confined in a jail, prison, penal institution, or correctional institution due to a conviction
for a criminal offense.
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Signature

Date

*I

-

(First Name, Middle Initial,
Last Name)

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a. Signature of Witness
Address (Number and Street)

Daytime Telephone Number (include area code)

-

Area Code

Telephone Number

-

Area Code

Telephone Number

b. Signature of Witness

Address (Number and Street)
City. State. ZIP Code

Daytime Telephone Number (include area code)
I

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

City, State, ZIP Code

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I certify that the information I gave to the RRB on this application is true to the best of my knowledge.

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Page 13

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Form AA-18

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(tbgf-f@

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I

How To Return Your Application
Before you return your application, check to make sure that:

I

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*

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.

I

When you received your application, you should also have received a pre-addressed return envelope. lf you
do not have this envelope, you can use any envelope as long as it is addressed to the RRB offtceshown on
page 15 of this application. No matter which envelope you use, you must put the correct postage on the envelope. Be careful to provide enough postage, because your application and the accompanying forms may weigh
more than a standard letter. The U.S. Postal Service will not deliver your application unless it has the correct
postage.
Make one final check before you seal the envelope to ensure that the following are enclosed:

I

*

NEEDED PROOFS

*

THE APPLICATION FORM ITSELF

I

> ADDITIONAL FORMS YOU WERE ASKED TO COMPLETE

\

Form AA-18

Note: Make no entries on page 15, which is the receipt for your claim. After the RRB receives your
application, they will complete the blanks on the receipt and send it back to you. When it is returned to
you, you will know that the RRB has received your application and has started the work needed to
determine if you are entitled to benefits. If you do not receive the receipt within two weeks after you filed
this application, please contact us so we can find out what is causing the delay.

a-$@

Page 14

~mployee'sName

I Railroad Retirement Board Claim Number

Applicant's Name

I Date Claim Received

Your application for a railroad retirement mother'slfather's and child's annuity has been received and will be processed as
quickly as possible. If you do not receive your first payment by
, you should contact the servicing field
office shown below. If you change your address, or if there is some other change that may affect your claim, you or your
representative should report the change. The changes to be reported are listed below. Always give us your claim number
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 3:30PM, Monday through Friday.

a Marriage-If you marry.

a Child Earnings-If any child's total earnings or self-

employment status changes from what was reported on
this application.

a 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.

a Work-If you or any chlid go to work for an employer in the

railroad industry.

a Social Security-If an application is filed for social

security benefits for you or a child based on any person's earnings record.

Applicant i s i n Your Care-If any person for
whom you are receiving an annuity dies marries, or
leaves your care.

a Address-If your address changes, even if your pay-

ments are sent to a financial organization.

a Criminal Offense-If you or any child are confined in a

a Earnings-If

your earnings change. On your application
you told us you expected total earnings for
to be
. You (are) (are not) earning more than
$
a month. You (are) (are not) performing
$
substantial services in self-employmqnt.

I

jail, prison, penal institution, or correctional facility due
to a conviction for a criminal offense.

Report at once i f work pattern changes.

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

To report any of the above changes, contact:

% Telephone Number:

If for some reason you cannot contact that office, you should contact:
U S RAILROAD RETIREMENT BOARD
844 N RUSH ST
CHICAGO IL 6061 1 -2092
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Page I 5

Form AA-18

(w-rn

Paperwork Reduction Act and Privacy Act Notices

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

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

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

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

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

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

3) the reason why the information is requested; and

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

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

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

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

Although the information we request is almost never used for
any purpose other than the payment of benefits under the
Railroad Retirement Act, the RRB does have the authority to
release information to the indicated individuals, organizations,
andlor agencies listed below without your approval:

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

1) An attorney, the 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.

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

We estimate this form takes an average of 27 to 47 minutes
per response to complete, including the time for reviewing the
instructions, getting the needed data, and reviewing the completed form. Federal agencies may not conduct or sponsor,
and respondents are not required to respond to, a collection of
information unless it displays a valid OMB number. If you
wish, send comments regarding the accuracy of our estimate
or any other aspect of this form, including suggestions for
reducing completion time, to Chief of lnformation Resources
Management, Railroad Retirement Board, 844 North Rush
Street, Chicago, Illinois 6061 1-2092.

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

Computer Matching and Privacy Protection Act Notice

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

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

5) The U.S. Treasury Department or U.S. Postal Service to
issue payments and to investigate lost, forged, or stolen checks.
6 ) Your last employer to make sure that you are eligible to
receive railroad retirement benefits and you continue to receive
any available medical benefits, and to any railroad industry
employer (or to its insurance company) to make sure that you
can receive any private retirement or insurance benefits which
may be offered by the employer.

7 ) The Social Security Administration, Centers for Medicare &
Medicaid Services, Pension Benefit Guarantee Corporation,
Form AA-18 $&@

Page 16