AA-20 (proposed) Application for Parent's Annuity

FORM APPROVED

UNITED STATES OF AMERICA

O.M.B. NO.3220-0030

RAILROAD RETIREMENT BOARD

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DO NOT WRITE IN THIS SPACE
OFFICIALLY FILED
MONTH
DAY

1

Application
for
Parent's Annuity

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YEAR

OFFICE NUMBER

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APPROVED

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DATE CODED
MONTH

APPLICATION NUMBER

DAY

YEAR

CODED BY

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General Instructions
Before you complete this application, be sure to read Part I of booklet RB-17, Survivor Annuities, which explains information you will need
to answer many of the questions in this application.
Please read "Important Notices" on page 12 of this application.
Print all answers in ink or use a typewriter. If you need more space than is provided to answer a question, use Section 10 for this purpose.
If you do not know the answer to a question, print "unknown" in the space provided for the answer.
When entering dates, always use numbers. Also, be sure there is one number in each box. For example, you would enter February 12,
2000, as:
MONTH

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

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

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Identifying Information
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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.

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EMPLOYEE'S NAME

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EMPLOYEE'S SOCIAL SECURITY NUMBER

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Identification

3

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Applicant
ldentification

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4

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APPLICANT'S NAME
a

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6

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EMPLOYEE'S RAILROAD RETIREMENT CLAIM NUMBER

5

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1

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STREETADDRESS
CITYAND STATE

c

ZIP CODE

d

COUNTY

DAYTIME TELEPHONE NUMBER

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Form AA-20

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Destroy Prior Editions

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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 ltem 7.
Date

7 Enter the employee's date of birth.

Residence

8

Month

>

Year

Day

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

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

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.

9

Q Yes

a No

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

Military

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

Yes

Q No

+ Go to Note and ltem 11

+ Go to ltem 13

Note: If answered "Yes,"you will have to submit proof of the employee's milita
service. If you cannot submit proof show, in Section 70,the branch of the service and the beginning and ending dates for each period of service.

Enter an " X in the appropriate box:
The employee had voluntary military service during the period
June 15, 1948, through December 15, 1950.
Enter an " X in the appropriate box:
The employee had nonrailroad earnings after leaving the military
service and before returning to the railroad.

Q Yes + Go to ltem 12
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Q No

+ Go to Item 13

Q Yes
>

Q No

Regardless of whether the employee was retired at death, show the name and address of each railroad or non-

Recent
Employment

I railroad employer for whom the employee performed any part-time or full-time work during the last 3 years he 1
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
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l a ~ a m e

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Address

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Began
Month

Ended

Year

Month

Year

City, State, ZIP Code

b

Name

Ended

Began

Address

Month

Year

Month

Year

City, State, ZIP Code

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c Name

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(Address

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Began
Month

Year

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Ended
Month

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Year

City, State, ZIP Code

Self14 Enter an "X" in the appropriate box:
Employment

The employee was self-employed during any of the
last three calendar years.

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Form AA-20

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.
Page 2

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Q Yes -+ Go to Item 15
Q No + Go to ltem 17

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Q Yes + Go to ltem 16
Q No + Go to ltem 17
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Employment
(Continued)

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16 Enter an "X" in the appropriate box(es):
Show the year or years in which the employee's net
earnings from self-employment were more than $400.

This year
Last year
Year before last

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

If the employee was alive on October 1, 1981, and had at least 25 years of railroad service, read the section
"Requirements The Employee Must Have Met" in Part I of the RB-17 booklet to find out what special conditions
may apply.
Note: You may be requested to submit proof to verify the statemen
made in ltems 17 and 18.
Enter an " X in the appropriate box:
The employee "involuntarily and without fault":
stopped working for his or her last railroad employer on or
after October I,1975, or

a Yes + Go to ltem 18

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No + Go to Section 4

was on furlough, leave of absence status, or absent because
of injury on October I,1975, and was never called back to
work for that employer.
Enter an " X in the appropriate box:
The employee declined an offer from a railroad employe; to return
to a job in the same "class or craft" as his or her last railroad job.

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0 Yes
O No

Information About The Employee's Family
Widow(er)

ase read the section nDefinition of a Widow(er)'s Annuity" in Part I1 of the RB-17 booklet to find out what
categories of widow(er) may be eligible for a railroad retirement annuity.

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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.

1 Children

Yes

O No

Please read the section "Definition o f a Child's Annuity" in Part I1 of the RB-17 booklet to find out what categories
of children may be eligible for a railroad retirement annuity.
Enter an "X" in the appropriate box:
There are children who may be eligible for an annuity.>

Yes

O No
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Answer ltem 21 only if the employee was male.
21 Enter an " X in the appropriate box:
A child of the employee is expected to be born.

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Relationship 23 Enter an "X" in the appropriate box:

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I am the employee's only living natural parent,
stepparent, or adoptive parent.

Enter an "X" in one box only to show your
relationship to the employee.

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Page 3

Yes

O No

0 Yes

a No

Q Natural Parent

+

Go to Item 29

Stepparent

+

Go to Item 25

Adoptive Parent + Go to ltem 26
Form AA-20

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StepParent
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25 Enter the date of your marriage to the employee's
natural mother or father.

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Adoptive
Parent

26 Enter the place (city and state or foreign country)
where you adopted the employee.

Month

Day

Year

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Go to ltem 29

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Month

Enter the date of the adoption.

Day

Year

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Enter the name of the court which issued the
adoption decree.

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Enter an " X in the appropriate box:
The employee was contributing at least one-half of the money and
goods needed to support me at the time the employee died or at
the beginning of the employee's period of disability if he or she
had one. (Consider the following as contributions to support:
money, food, clothes, paying bills, providing rent-free housing.)

m Yes +Go to Note and ltem 30
Q No

+Go to Section 11

Note: If answered "Yes,"you will have to complete and return to the RRB,
Form 6-134, Statement Regarding Contributions and Support.
Enter an "X" in the appropriate box:
I remarried after the employee's death.

m Yes + Go to ltem 31

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Q No

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Go to ltem 32

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

Date
Married

Your Husband's or
Wife's Name

a

b

c

Security
Number
Criminal
Offense

32 Enter your social security number.
If none enter "TO BE SUBMITTED."

How Marriage Ended
(Check One)

Month

Month

Day

Day

(If Marriage Never Ended
Leave Blank)
Year

Year

Month

Day

Year

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m
m
m
m
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Q
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Spouse's death
Divorce
Annulment
Spouse's death
Divorce
Annulment
Spouse's death
Divorce
Annulment

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33 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 convictionfor a criminal offense.

m Yes + Go to ltem 34
No

+ Go to Section 6