AA-17cert Application Summary and Certification

Form Approved

OMB 3220-0030

United States of America
Railroad Retirement Board

APPLICATION SUMMARY and CERTIFICATION
Employee's Name
RR Claim No.
The following information was either supplied by or verified by you in support of your
application for (application type) under the Railroad Retirement Act. After you have
reviewed the information, make any changes on the summary, initial the change and sign
the certification on the last page. Return the certification and all pages of the summary to
the RRB.

Employee Information
ber
Social Security Nurr~
Date of Birth
Date of Death
Military Service
1 The err~ployeewas not in active military service after September 7, 1939.

2

The employee had military service after September 7, 1939.

Recent Employment
3 The employee had not worked in the two years before death.
4

The employee worked for the following companies in the last two years:
(Company Name)
(Company Name)
(Company Name)

from 99/99/9999 to 99/99/9999
,from 99/99/9999 to 99/99/9999
,from 99/99/9999 to 99/99/9999

5

The employee did not have self-employment earnings in any of the last three years.

6

The employee's net earnings from self-employment were less than $400 in each of
the last three years.

7

The employee's net earnings from self-employment were $400 or more in one of the
last three years.

Railroad Employment

8 The employee had a current connection with the railroad industry.

RRB Form AA-17cert (09-06)

32948 64790 22000 06051 32704

Page I

United States of America
Railroad Retirement Board

Form Approved

OMB 3220-0030

9 A current connection with the railroad industry is "deemed" because the employee:
1
2
3

Was alive on October I , 1981 and had at least 25 years of railroad service, and
Alnvoluntarily and without fault" stopped working for the railroad on or after
October 1, 1975 and was never called back to work for the railroad employer,
and
Did not decline an offer from a railroad employer to return to a job in the same
"class or craft" as the last railroad job.

10 The employee does not have a current connection with the railroad industry.
Employee's Family
11 The employee was not survived by a widow(er) or surviving divorced spouse who may
be entitled to monthly benefits.

12 The employee was not survived by children or grandchildren who may be entitled to
monthly benefits.
13 The employee was not survived by a parent who may be entitled to monthly benefits.
14 The employee was survived by a widow(er) or surviving divorced spouse who may be
entitled to monthly benefits.
Name
Relationship
Social Security Number
15 The employee was survived by a cl-~ildor grandchild who may be entitled to monthly
benefits.
Name
Relationship
Social Security Number
16 The employee was survived by a parent who may be entitled to monthly benefits.
Name
Relationship
Social Security Number
Applicant Information
Name and Address
Number
Social Sec~.~rity
Date of Birth
Daytime Telephone Number
Type of ApplicantionFiled (insert application type)

RRB Form AA-17cert (09-06)

32948 64790 22000 06051 32704

Page 2

Form Approved

OMB 3220-0030

United States of America
Railroad Retirement Board

17 You applied for this benefit based on your rela1:ionship to the employee.
18 You applied for this benefit based on your relationship to the employee and that you
are disabled.
19 You applied for this benefit based on your relationship to the employee and that you
have the following children in your care.
Name

SS Nuniber

DOB

Filing For

20 You applied for this benefit based on your relationship to the employee and that you
are a full-time student.
21 You have requested that any payment due you be sent to the following bank account:
Bank Name
Routing Number
Account Nuniber
Account Type
22 You have requested that any payment due you be sent to the address shown above.
Applicant's Marriages

23 You were married to someone other than the employee.
24 You were not married to anyone other than the employee.
25 You have married since the employee's death.
26 You have remarried since your divorce from the employee.
27 You have not remarried since your divorce from the employee.
28 You have never been married.
29 You were married and that marriage ended on n-lni I dd I yyyy.
30 You are currer~tlymarried.
31 You have remarried since the employee's death.
32 You have not remarried since the employee's death.
RRB Form AA-17cert (09-06)

32948 64790 22000 06051 32704

Page 3

Form Approved

OMB 3220-0030

United States of America
Railroad Retirement Board

Criminal Offense Information
33 Within the past 12 months you have not been imprisoned or been given a sentence of
confinement due to a conviction for a criminal offense.
34 Within the past 12 months you have been imprisoned or been given a sentence of
confinement due to a conviction for a crirnilial offense.
Other Government Benefits
35 You have filed or plan to file in the next three months for Social Security benefits on
your own account.
36 You have filed or plan to file in the next three months for Social Security benefits on
the account of:

Name

Social Security
Nurr~ber
37 You have not filed nor plan to file in the next three months for Social Security benefits
on any account number.
38 You have not filed nor do you plan to file in the next three months for Social Security
benefits on an additional account number.
39 You are currently receiving a social security benefit.
39 You are not receiving a social security benefit.
40 In the past month you have filed or plan to file in the next three months for Railroad
Retirement benefits based on your own earnings.
41 In the past month you have filed or plan to file in the next three months for Railroad
Retirement benefits based on the account of:

Name

Social Security Number

42 In the past molitli you have not filed nor plan to file in the next three months for
Railroad Retirement benefits on any account number.
43 You are currently receiving a railroad retirement annuity.
44 You are not receiving a railroad retirement annuity.
RRB Form AA-17cert (09-06)

32948 64790 22000 06051 32704

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Form Approved

OMB 3220-0030

United States of America
Railroad Retirement Board

45 You are receiving a pension based on your earnings from a Federal, state or local
government agency.
46 You received a lump-sum payment instead of a monthly pension from a Federal, state
or local government agency.
47 You are not receiving nor do you expect to receive a pension or lump-sum payment
based on your earnings from a Federal, state or local government agency.
48 You expect to receive a pension or lump-sum payment based on your earnings from a
Federal, state or local government agency.
Earnings Information

49 In 9999, (last year) your total earnings were $999,999.99
50 In 9999, (last year) your earnings were less than $999,999.99
51 In 9999, (last year) you earned more than $9999 in each month.
52 In 9999, (last year) you earned less than $9999 in the following months:
January February March April May June July August September October
November December
53 In 9999, (current year) you expect your total earnings will be $999,999.99.
54 In 9999, (current year) you expect your total earnings will be less than $999,999.99
55 In 9999, (current year) you expect to earn more than $9999 in each month.
56 In 9999, (current year) you expect to earn less than $9999 in the following months:
January February March April May June July August September October
November December
57 In 9999, (next year) you expect your total earnings will be $999,999.99.
58 In 9999, (next year) you expect your total earnings will be less than $999,999.99.
Railroad Work

59 You worked for a railroad or other employer in the railroad industry.

60 Your date last worked for a railroad or other employer in the railroad industry was

RRB Form AA-17cert (09-06)

32948 64790 22000 06051 32704

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Form Approved

OMB 3220-0030

United States of America
Railroad Retirement Board

mni 1dd 1yyyy.
61 This year, you worked for a railroad or other employer in the railroad industry in the
following months.
January February March April May June July August
September
October November December
62 Last year, you worked for a railroad or other eniployer in the railroad i~idustryin the
following months.
January February March April May June July August
September
October November December
63 You have not worked for a railroad or other employer in the railroad industry.
Beginning Dates and Filing Dates

64 You requested your annuity begin on tlie earliest date permitted by law, even if you
will receive a reduced annuity.
65 You have selected mmlddlyyyy for the beginning date of your annuity.
66 This application will protect yo[-lrfiling date for Social Security benefits.
67 You do not want this application to protect your filing date for Social Security benefits.
Medicare

68 You are er~rolledin the Medicare Medical lnsurance Plan (Part B).
69 You wish to enroll in the Medicare Medical Insurance Plan (Part B).
70 You do not wish to enroll in the Medicare Medical Insurance Plan (Part B) at this time.
71 You are claiming a special enrollment period based on coverage by an employer
group health plan.
72 You are clairrri~igpremium surcharge relief based on coverage by an employer group
health plan.

Application for (Application Type - Certification)
RRB Form AA-17cert (09-06)

32948 64790 22000 06051 32704

Page 6

United States of America
Railroad Retirement Board

Form Approved

OMB 3220-0030

Employee's RR Claim Number
Employee's Name
Employee's Social Security Number
Applicant's Name
Applicant's Social Security Number

I certify that the information I have given to the Railroad Retirement Board (RRB) in
relation to this application is true to the best of my knowledge. I know that if I make a
false or fraudulent statement in order to receive benefits from the RRB, I am committing a
crime which is punishable under Federal law.
I have received and reviewed a summary of the information I provided. I understand that I
have an obligation to advise the RRB immediately if there are any errors in the summary I
received, and have made and initialed any corrections on the Summary being returned to
the RRB.
I have received and reviewed the booklets RB-17 SurvivorAnnuityand RB-9s Events that
Affect a Survivor Annuity. I understand that 1 am responsible for reporting events that
would affect my annuity. Printed if application type is widow(er), child or parent who are
FRA or older
I have received and reviewed the booklets RB-17 Survivor Annuity, RB-9s Events that
Affect a Survivor Annuity and form G-77 How Earnings Affect Payment of Survivor
Annuities. I understand that I am responsible for reporting events that w o ~ ~affect
l d my
annuity. Printed i f application type is widow(er), child or parent who are under FRA
I have received and reviewed the booklets RB-17 Survivor Annuity, RB-17b
Widow(er)'s Disability Benefits and RB-9s Events that Affect a Survivor Annuity. I
understand that I am responsible for reporting events that would affect my annuity.
Printed i f application type is disabled widow(er)
I have received and reviewed the booklets RB-17 Survivor Annuity, RB-19a Child
Disability Benefits and RB-9s Events that Affect a Survivor Annuity. I understand that I
am responsible for reporting events that would affect my annuity. Printed i f application
type is disabled child.
I agree to immediately notify the RRB, if
I remarry;
I marry;
RRB Form AA-17cert (09-06)

32948 64790 22000 06051 32704

Page 7

Form Approved
OMB 3220-0030

United States of America
Railroad Retirement Board

I begin to receive a pension or receive a lurr~psum payment based on my earnings
from a Federal, state or local government agency;
The amount of my pension based on my earnings from a Federal, state or local
government agency changes;
I file for social security benefits on any person's account;
Benefits I receive directly 'from the Social Security Administration are adjusted for a
reasoli other than normal cost-of-living increases
I go to work for a railroad or railroad labor organization;
My expected earnings amount changes;
My address changes;
My bank account changes;
Any person for whom I am receiving benefits dies or leaves my care;
I am confined to a jail, prison, penal institution or correctional institution due to a
conviction for a criminal offense.

Signature (First Name, Middle Initial, Last Name)

Date

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

Signature o f Witness

Signature o f Witness

Address (Street, City, State and ZIP Code)

Address(Street, City, State and ZIP Code)

Daytime Telephone Number

()
Daytime Telephone Number

RRB Form AA-17cert (09-06)

32948 64790 22000 06051 32704

Page 8