AA-19 (proposed) Application for Child's Annuity

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

FORM APPROVED
O.M.B. NO.3220-0030

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APPLICATION
FOR
CHILD'S ANNUITY

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

YEAR

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APPROVED

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DATE CODED

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APPLICATION NUMBER

MONTH

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DAY

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YEAR

I I CODED BY

r
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-

-

-

-

-

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Before you complete this application, be sure to read Part 1 of booklet RB-17, Survivor Annuities, which explains information
you will need to answer many of the questions in this application.
If filing for a child3 disability also complete Form AA-I9a. If filing for a student's annuity also complete Form G-315.

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Please read "Important Notices" on page 14 of this application.

Print all answers in ink or use a typewriter. If you need more space than is provided to answer a question, use Section 10 for
this purpose. If you do not know the answer to a question, print "unknown" in the space provided for the answer.
When entering dates, always use numbers. Also, be sure there is one number In each box. For example, you would enter
February 13,2000, as:
MONTH
DAY
YEAR

012

113 2 1 0 1 0 1 0 -

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.

1

If you are completing this application on behalf of the child, you must answer each question as it applies to the child.

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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.
* If the information is not correct, cross out the incorrect information and enter the correct information above it.
If the information is missing, fill it in.
Employee
identification

I EMPLOYEE'S NAME
2

1

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EMPLOYEE'S SOCIAL SECURITY NUMBER

EMPLOYEE'S RAILROAD RETIREMENT CLAIM NUMBER

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Applicant
4
Identification

APPLICANT'S NAME

5

6

+

-

a

STREET ADDRESS

b

CITY AND STATE

c

ZIP CODE

d

COUNTY

+-

DAYTIME TELEPHONE NUMBER
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Form AA-19

M-MDestroy Prior EditionsI

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

17

Birth Date

Residence

II

MONTH

Enter the employee's date of birth.

II

DAY

YEAR

8 Enter the state (or country if other than United States) which
was the employee's permanent home at the time of death.
I

If the employee was age 62 or older when he or she died, go to ltem 10.
Disability

a Yes
a No

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 Service" in the RB-17 booklet to find out how active
military service is determined.
10 Enter an "X" in the appropriate box:
The employee was in active military service after
September 7, 1939.

+Go to Note and ltem 11
+Go to ltem 13

Yes
No
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Note: If answered "Yes,"you will have to submit proof of the employee's military service. If you cannot submit
prool show the branch of the service and the beginning and ending dates for each period of service in Section 10.
11 Enter an "X" in the appropriate box:
The employee had voluntary military service during the
period June 15,1948, through December 15,1950.

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

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

CI Yes
CI No
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Recent

13 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 a, the second in b, and so on.
Enter the date each job began and ended.
Name and Address of Employer

Street Address

City, State & ZIP Code

II

Street Address

City, State & ZIP Code

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Self-

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City, State & ZIP Code

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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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Page 2

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Ended
Month
Year

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+ Go to ltem 15
+ Go to ltem 17

CI
CI

Yes + Go to ltem 16
IVo + Go to ltem 17

a This year
a Last year
a Year before last
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Ended
Month I Year

Yes
No

1

16 Enter an "X" in the appropriate box(es) to show the year
or years in which the employee's net earnings from
self-employment were more than $400.
'arm AA-19 (gXJ@)

II

Began
Month
Year

c. Name
Street Address

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Began
Month I Year

b. Name

1

Ended
Month
Year

Began
Year
Month

a. Name

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Answer Items 17 and 18 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 19.

Railroad

Pldase read the section "Requiremenfs The Employee Musf Have Met" in the RB-17 booklet to find out what special conditions may apply if the employee was alive on October 1, 1981, and had at least 25 years of railroad service.
Note: You may be requesfed to submif proof to verify the stafemenfs made in lfems 17 and 18.

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

a Yes +- Go to Item 18
a No +- Go to Item 19

stopped working for his or her last railroad employer on or
after October I,1975, or
was on furlough, leave of absence status, or absent because
1975, and was never called back to
of injury on October I,
work for that employer.

a Yes
a No

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.

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

a

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

Date
Married
Month

Year

Day

How Marriage
Ended
(Check One)

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

Date Marriage
Ended

a Employee's Death

B
a
a Employee's Death
a Spouse's Death
a Divorce
aAnnulment
a Employee's Death
a Spouse's Death
a Divorce
aAnnulment

Month

Day

Year

Month

Day

Year

Month

Day

Year

ouse's Death
Divorce
sp
Annulment

b

C

Day

Year

Month

Day

Year

Please read the section "Definifion Of A Widow(er)'s Annuify" in the RB-17 booklet to find out what categories of
widow(er) may be eligible for a railroad retirement annuity.

Widow(er)

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Month

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a Yes

20 Enter an "X" in the appropriate box:
There is a widow(er), remarried widow(er), or surviving divorced
spouse who may be eligible for a widow(er)'s annuity.
21 Enter an " X in the appropriate box:
The employee was survived by a parent.
22 Enter an "X" in the appropriate box:
The parent was dependent on the employee for
one-half of his or her s u. ~. ~ o r t .

0No

a Yes -+ Go to ltem 22
a No -+ Go to Section 4
a Yes -+ Go to ltem 23
a No --, Go to Section 4
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23 Print the requested information for each dependent parent of the employee.

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Name of Parent
a

b

(

Date of Birth
Month

Month

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Address and Telephone Number
Address

Year
Day -

Telephone Number (include area code)
(
1
Address

Year
Day -

Telephone Number (include area code)
(
1
Page 3

Form AA-I9

(M-#$(]

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

24 Print the requested information for every child for whom you are filing this application who may be entitled to a
child's annuity. Print the youngest child in a, the second youngest in b, and so on. If a child does not have a
social security number, enter "TO BE SUBMITTED."
Note: If Stepchild or Grandchild is checked below, you must also complete Form G-139, Statement
Regarding Contributions and Support of Children.
Relationship to
Employee
(Check One)

Child's Full Name and
Social Security Number
a

a Adopted [Natural]
a Grandchild
a
Other
D Stepchild

b

Enter an 'X in the
appropriate box:
The Child is Living
with Me

Date of Birth

Month

Day

Year

Yes

O

No

,:,waral
Grandchild

a Stepchild
[Natural]
a
a Grandchild
Adopted
a other
a Stepchild
-NatuW
a Adopted a Grandchild

c

d

Stepchild

0

Month

Month

Day

Year

Day

Year

Yes

.aNo

Yes

O No
Month

Day

Year

O No

Other

NahW

e

Grandchild
a Adopted a
a Stepchild a Other

F e r y child in ltem 24 is living with you,
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gz

Month

Day

Year

Yes

O No

ltem 26.

-

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Children
Not Living
With
Applicant

25 Print the requested information for every child in ltem 24 who is not living with you. Print the youngest in a.

Legal
Guardian

26 Enter an " X in the appropriate box:
A court has appointed a legal guardian for a child in Item 24.

First Name
of Child

Person with Whom Child is Living
Relationship to
Name
Child

Child's Address

Yes +Go to Item 27

m No

+Go to Item 28

27 Print the requested information for every child in ltem 24 who has a court-appointed legal guardian.
Print the youngest child in a, etc.

(

First Name of Child

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Name and Address of Guardian

Page 4

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Married
Children

a Yes +Go to ltem 29
a No +Go to Item 30

28 Enter an "X" in the appropriate box:
One or more of the children in ltem 24 is or has been married.

29 Print the requested information for every child in ltem 24 who has ever been married. Print the youngest child in a.

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Child's Married Name

GrandChildren,
Other
Children

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Date Married

Date Marriage Ended
if applicable

a

Month

Day

Year

Month

Day

Year

b

Month

Day

Year

Month

Day

Year

If 'hgh=mW[Natural] or "Adopted" was checked for every child in ltem 24, go to ltem 32.

a Yes +Go to Item 32

30 Enter an "X" in the appropriate box:
Every "Grandchild" or "Other Child" in ltem 24
was living with the employee at the time the employee died.

No

+Go to Item 31

31 Print the requested information for every "Grandchild" or "Other Child" in ltem 24 who was not living with the
employee at the time the employee died. Print the youngest child in a, etc.

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First Name of Child

Zhildren
-or Whom
You Are

lot Filing

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Person with Whom Child Lived at the Time the Employee Died

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Name

I Relationship to Child

Address

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

a Yes

a Go to Item 33

Q No

+ Go to ltem 34

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

Child's Full Name

Information About The Applicant

a Yes a Go to Item 39
a No +Go to ltem 35

34 Enter an " X in the appropriate box:
I am a child filing for myself.

35 Print your relationship to the youngest child in ltem 24,
36 Enter an " X in the appropriate box:
My relationship to every child in ltem 24 is the same.

Yes

+ Go to Item 38

Q No a Go to ltem 37
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Page 5

Form AA-19

@&-4

1 Relationship 1 37 Print the requested information for every child for whom your relationship differs.
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Child's Name
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Your Relationship to Child

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Pnn'4

Social
Security
Number
Criminal
Offense

38 ~ n t eyour
r
social security number if you are the
parent of at least one child in ltem 24.
39 Enter an "X" in the appropriate box:
Within the past 12 months, a child named in ltem 24 has been imprisoned or
aiven a sentence of confinement due to a conviction for a criminal offense.

IJ Yes +Go to ltem 40
IJ No +Go to Section 6
Month

140 Enter the date of the conviction.

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41 Enter the date of the sentence of confinement.
42 Enter the date that confinement began.

Day

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Year

Month

Day

Year

Month

Day

Year

IJ Yes +Go to ltem 44
IJ No + Go to Section 6

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

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Month

44 Enter the date confinement ended.

Day

Year

Information About Applicant's Other Government Benefits
When answering Items 45 through 52, consider only the children listed in ltem 24.
Social
Security
BenefitsFiled For

45 Enter an "X" in the appropriate box:
An application has been filed for benefits under the Social
Security Act for any child.

IJ Yes +Go to ltem 46
IJ No +Go to ltem 47

46 Print the requested information for every child for whom a social security application has been filed. Use as
many lines as needed beginning with a.
Child's Name

Social
Security
BenefitsFuture
Filing

I

Person Whose Record
was Filed On

47 Enter an "X" in the appropriate box:
An application will be filed in the future for benefits
under the Social Security Act for any child.

Form AA-19

Social Security Number Filed On

-

a Yes +Go to ltem 48
IJ No

Go to ltem 50

48 Print the name of the person on whose record the child
will file.
49 Enter that person's social security number.

Railroad
Retirement
Benefits

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50 Enter an "X" in the appropriate box:
An application has been filed or will be filed for monthly
railroad retirement benefits for any child based on
someone other than the employee.

(a-w)

Page 6

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IJ Yes + Go to ltem 51

a No +Go to Section 7

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Railroad

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Benefits

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51 Print the name of the person on whose record the
application has been filed or will be filed.
52 Enter that person's Railroad Retirement Board claim
number, including the letter prefix.

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Prefix

If only six numbers,
enter here
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Information About Work And Earnings
Please read the section "How Earnings Affect An Annuity" in the RB-17 booklet to find out how work and earnings can affect a
child's annuity. Also, please refer to Form 6-77, How Earnings Affect Payment of Survivor Annuities, for the exempt
amounts to use when answering ltems 53 through 59.
When answering ltems 53 through 61, consider only the children listed in ltem 24.

I Answer Items 53 and 54 only if the employee died before January 1 of this year.

1

1

a Yes +Go to ltem 54
a No +Go to ltem 55

53 Enter an "X"in the appropriate box:
The total earnings of any child for all employment last year were
more than the annual earnings exempt amount shown on Form G-77.

Earnings
last Year
(Year)

54 Print the requested information for every child 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 a.
a

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

1 Child's Name

3 Enter an "X" in the appropriate box:
Did the child earn more than the monthly earnings exempt amount in
employment for hire or perform substantial services in self-employment in
everv month last vear?

1
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(

l

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

Yes

a No

~

r

3 Enter an 'X" in the appropriate box:
Did the child earn more than the monthly earnings exempt amount in
employment for hire or perform substantial services in self-employment in
every month last year?

c

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

Yes

O No

~r-pqrpq~rpqrpz
1

1 Child's Name

I

-

2 Total Earnings for Last Year
(Show ~ o l l a r sOnly)
$

3 Enter an "X" in the appropriate box:
Did the child earn more than the monthly earnings exempt amount in
employment for hire or perform substantial services in self-employment in
every month last year?

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Earnings
This Year
(Year)
.

4 Enter an "X"next to each month last year in
which the child did not earn more than the
monthly earnings exempt amount or perform
substantial services in self-em~lovment.

l

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

b 1 Child's Name

1

p

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~

a Yes
a
NO

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A

Ir-piqrpq-piqrpiqrpqml

55 Enter an 'X" in the appropriate box:
The total earnings of any child for all employment this year
will be more than the annual earnings exempt amount.
Page 7

a Yes + Go to ltem 56
a No -+ Go to ltem 57
(a-@
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Form AA-19

Earnings
This Year
Con't

56 Print the requested information for every child whose total earnings for this year are expected to be more
than the annual earnings exempt amount. Use as many lines as needed beginning with a.

1

1

a 1 Child's Name

I

2 Total Earnings for This Year
(Show ~ o l l a kOnly)

I

3 Enter an " X in the appropriate box:
Did the child earn more than the monthly earnings exempt amount in
employment for hire or perform substantial services in self-employment in
every month this year?
4 Enter an "X" next to each month this year in
which the child did not, or does not expect to,
earn more than the monthly earnings exempt
amount or perform substantial services in
self-employment.

~

a Yes
a No

~

J

A

~~~~~~
2 Total Earnings for This Year
(Show Dollars Only)
$

b 1 Child's Name

3 Enter an "X" in the appropriate box:
Did the child earn more than the monthly earnings exempt amount in
employment for hire or perform substantial services in self-employment in
everv month this vear?
4 Enter an "X" next to each month this year in
which the child did not, or does not expect to,
earn more than the monthly earnings exempt
amount or perform substantial services in
self-employment.
2 Total Earnings for This Year
i Child's Name
(Show Dollars Only)
$

JAN^^^

~

c

~

3 Enter an "X" in the appropriate box:
Did the child earn more than the monthly earnings exempt amount in
employment for hire or perform substantial services in self-employment in
every month this year?
4 Enter an "X" next to each month this year in
which the child did not, or does not expect to,
earn more than the monthly earnings exempt
amount or perform substantial services in

~
~

Earnings
Next Year

57 Enter an " X in the appropriate box:
This application is being returned in September,
October. November. or December.

(Year)

58 Eriter an "X" in the appropriate box:
The total earnings of any child for all employment next year will be
more than this year's annual earnings exempt amount.

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.

a Yes
a No
J
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A
U

a Yes +- Go to ltem 58
a No +- Go to ltem 60
a Yes +- Go to Item 59
a No +- Go to ltem 60

59 Enter the requested information for every child whose total earnings for next year are expected to be more
than the annual earnings exempt amount. Use as many blanks as needed beginning with a.
Expected Earnings Next Year
Child's Name
(Show Dollars Only)

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'arm AA-19

(a-f@J

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Page 8

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Railroad
Work

60 Enter an "X" in the appropriate box:
Any child has worked for a railroad or other employer in
the railroad industry.

a

Yes +DGo to Item 61
No --, Go t o Section 8

1 61 Print the requested information for every child who has worked for a railroad or other employer in the railroad I
industry. Use as many lines as are needed beginning with a.
1 Child's Name

a

2 Railroad Employer

1 Month 1

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3 Date Last Worked

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

Day ( Year

W
I
~

/

ml

J

U

5 If you expect the annuity to begin before January 1st
of this year, enter an " X next to each month of the
last year during which the child worked for an
employer in the railroad industry.
1 Child's Name

b

13

2 Railroad Employer

1

Month

Date Last Worked

I

Day

I
I

Year

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

5 If you expect the annuity to begin before January Ist
of this year, enter an X" next to each month of the
last year during which the child worked for an
employer in the railroad industry.
1 Child's Name

2 Railroad Employer

1 Month 1

3 Date Last Worked

I

Day

I

I

Year

I

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

15

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

~(mmimm

Filing Date
Answer only if you are disabled or otherwise eligible for social security disability or survivor benefits and you have not filed
an application for such benefits.
Filing
Prokction

62 Enter an " X in the appropriate box:
I also want this application used to protect my filing date
for social security benefits.
Page 9

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Yes
No
Form AA-19

(M-m

-1

Direct Deposit
Benefits are generally paid by Direct Deposit to your bank, savings and loan, credit union, or other financial institution.
To provide the information we need to correctly deposit your payments, attach a voided personal check and go to Section 10,
or call your financial institution for the information you need to complete Items 63-67. If you do not have a bank account, or
receiving your payments by Direct Deposit would cause you a hardship, go t o Item 68.

1

Direct
Deposit

63 Print the name of your financial institution.
Area Code

64 Print the telephone number (including area code)
of your financial institution.

Telephone Number

65 Print the routing transit number of your
financial institution.
66 Print your account number.

m Checking
m Savings

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

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Go To Section 10

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

Remarks

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

Form AA-19 (R6-m)

Page 10

Certification
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Certification 70 Enter an "X" in the appropriate box:

0 Yes +Go to Note and ltem 71
0 No + Go to ltem 71

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 o f Payee.
71 1 know that if I make a false or fraudulent statement in order to receive benefits from the Railroad Retirement
Board (RRB), I am committing a crime which is punishable under Federal law.
I have received the booklet RB-17, Survivor Annuity, and the booklet RB8s, 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.

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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.
I agree to immediately notify the RRB:
If I/any child marries;
If I/any child over age 18 ceases to attend school full time;
If an application is filed for social security benefits on any person's earnings record;
If I / any child goes to work for an employer in the railroad industry;
If I / any child will earn more than the annual earnings exempt amount, and it was not reported on the
application;
If the reported earnings estimate changes;
If my address changes;
If any child for whom I am receiving benefits dies or leaves my care;
If I am, orany child is, confined in a jail, prison, penal institution, or correctional institution due to a
conviction for a criminal offense.
Signature
(First Name, Middle Initial,
Last Name)

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b
I

Month

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Dav

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Year

Date
72 If this certification is signed by mark ("X") in ltem 71, two witnesses who know the person signing must sign
below, giving their full addresses and daytime telephone numbers.
a. Signature of Witness

Address (Number and Street)

,
City, State, and ZIP Code

Area Code

Telephone Number

Area Code

Telephone Number

Daytime Telephone Number
b. Signature of Witness

Address (Number and Street)

City, State, and ZIP Code

Daytime Telephone Number
Page 11

Forrn AA-19 (@-?j&

How To Return Your Application

I

Before you return your application, check to make sure that:

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Every question that applies to you has been answered.

*
*
*

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(

You have entered "unknown" in any answer space for which you were unable to answer a question.
You have signed and dated the application.
You have included all the needed proofs listed in the letter you received with this application.

When you received the child's application, you should also have received a pre-addressed return envelope. If you
do not have this envelope, you can use any envelope as long as it is addressed to the RRB office shown on page
13 of this application. No matter which envelope you use, you must put the correct postage on the envelope. Be
careful to provide enough postage, because your application and fhe 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
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*
*
*

NEEDED PROOFS
THE APPLICATION FORM ITSELF
ADDITIONAL FORMS YOU WERE ASKED TO COMPLETE

Note: Make no entries on page 13, which is the receipt for your claim. Afier the RRB office
receives the child's application, they will complete the blanks on the receipt and send it back to
you. When it is returned to you, you will know that the RRB has received the application and has
started the work needed to determine if the child is entitled to benefits. If you do not receive your
receipt within two weeks afier you filed this application, please contact us so we can find out what
is causing the delay

Form AA-19

(@-a)

Page 12

Employee's Name

1 Railroad Retirement Board Claim Number

Applicant's Name

I Date Claim Received

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

Work-If a child goes to work for an employer in the
railroad industry.

Death-If any child dies.
Marriage-If

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

Social Security-If an application is filed for
social security benefits for any child based on
any person's earnings record.

Child is i n Your Care--If any child leaves your care.

Earnings-If a child's earnings change. On your application you told us you expected total earnings for
to
. He or she (is) (is not) earning more than
be $
a month. He or she (is) (is not) performing
$
substantial services in self-employment.

Report at once if work pattern changes.

Criminal Offense-If any child is confined in a jail,
prison, penal institution or correctional facility due to a
conviction for a criminal offense.
School Attendbncs-If a child over age 18 stops attending
school full-time.

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

To report any of the above changes, contact:

b

Telephone Number:

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

b

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

I

Page 13

Form AA-19 @&@

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 frsm 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) Information about the determination and recovery of an
overpayment made to you may be released to any other person
from whom any portion of the overpayment is being recovered.
14) Your name and address may be released to a Member of
Congress to inform you about current or proposed legislation
which could affect the railroad retirement system.

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:

15) ~rofeskionalStandard 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.

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

2) Other people who are receiving benefits based on the same
railroad retirement account as you are if the information
affects their payments from the RRB.
3) A person who will receive benefits on your behalf if the
RRB decided that some medical condition keeps you from
receiving your own benefits; such information may also be
released in determining whether such a medical condition
exists and who is suitable to receive such benefits for you.
4) To people or organizations who are working for the RRB;
such information may include medical records.

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

5) The U.S. Treasury Department or U.S. Postal Service to
issue checks and to investigate lost, forged, or stolen checks.

6 ) Your last employer to make sure that you are eligible to
receive railroad retirement benefits and you continue to receive
any available medical benefits, and to any railroad industry
employer (or to its insurance company) to make sure that you
can receive any private retirement or insurance benefits which
may be offered by the employer.
7) The Social Security Administration, Centers for Medicare
& Medicaid Services, Pension Benefit Guarantee Corporation,

-arm AA-19 (05-04)

Page 14