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pdfUnited States of America
Railroad Retirement Board
Form Approved
OMB No. 3220-0002
Do Not Write In This Space
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Month
Application
For Determination
Of Employee's Disability
Officially Filed
Day
,
Approved
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Oftice Number
Year
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Date Coded
AppIic;tion Yumbyr
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General Instructions
Before you complete this application, be sure to read Part 1 of booklet RB-Id, Employee Disability Benefits, 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.
Type or print legibly in ink. If you need more space than is provided to answer a question, use Section 9 for this purpose. If
you do not know the answer.to a question, print 'Unknown" in the 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
June 06,2007, as:
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 t o 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 5 for accuracy.
b
b
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If the information is correct, go to Section 3.
If the information is not correct, enter the correct information.
If the information is missing, fill it in.
Employee
ldentilication
1 Employee's Name
2 Employee's Railroad Retirement Claim Number
A
3 Employee's Social Security Number
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4a Employee's Street Address
b City and State
c ZIP Code
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d County
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5 Daytime Telephone Number
Form AA-Id (09-07) Destroy Prior ~ d i t G
lnformation About Your Medical Condition
6 Describe the medical conditions causing you to file. Enter the exact diagnosis if known and any secondary condition.
Also enter if no medical records are being forwarded for each condition described.
Medical
Condiaon
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Kid.
7 Enter the date this condition began to affect
your ability to work.
Renan
Month
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How
8 Enter an " X in the appropriate box:
Condilion Have you worked since the date in ltem 7?
Affeds
Day
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Year
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9 Enter an 'X" in the appropriate box:
Has your condition caused you to change any aspect of your
work (such as job duties, hours of work, attendance, etc.)?
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Yes b
Go to ltem 9
No
b
Gotoltemll
Yes b
Go to Item 10
No
Go to Item 11
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10 Explain what the changes in your work circumstances were, the dates they occurred, and why your condition made these
changesnecessary.
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CHANGES
DATES
CONDITION
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I 1 Enter the date you could no longer work
because of vour condition.
When
Unable
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Month
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Day
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Year
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12 Describe how your condition prevents you from working.
Work
13 Enter an "X"in the appropriate box:
Does your condition prevent you from working now?
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14 Enter the date you again became able to work.
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Yes b Go to Section 4
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No
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Go to ltem 14
Month
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Day
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Year
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lnformation About Your Medical Care
Medical
15a Enter an "X" in the appropriate box:
Care or
Have you received medical care or b'een examined for
Bamirrafian
your condition since the date in ltem 77
b Enter an "X" in the appropriate box:
Are you scheduled for any additional medical care for your
condition (i.e., surgeries, etc.) after you file this application?
Yes F
O
~
o
Yes b
[13NO
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Explain below
Gotolteml6
Explain:
16 Enter an "X" in the appropriate box:
Have you been treated or tested (inpatient or outpatient)
at a hospital, institution, or clinic, including a
Department of Veterans Affairs or other government facility?
Form AA-ld (09-07) Page 2
Treatment
or T e s h
m] Yes
O N o
b Go to Item I 7
b Gotoltem18
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17 Enter information about each hospital, institution, or clinic where you have received treatment or care since the date in
Item 7.
1 Address of Facilitv (Street Address, City, State, and ZIP Code)
a Name of Facilitv
Attending Physician's Name
Enter an " X in the appropriate box:
inpatient
Outpatient
Telephone Number (Include Area Code)
Patlent Number
(
Dates Treated or Tested
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Describe Type of Treatment or Testing
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b Name of Facility
Address of Facility (Street Address, City, State, and ZIP Code)
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Attending Physician's Name
inpatient
Outpatient
Telephone Number (Include Area Code)
Patient Number
(
Dates Treated or Tested
]
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Describe Type of Treatment or Testing
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c Name of Facility
Address of Facility (Street Address, City, State, and ZIP Code)
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Attending Physician's Name
Enter an "X" in the appropriate box:
Inpatient
Outpatient
Telephone Number (Include Area Code)
Patient Number
(
Dates Treated or Tested
]
1
Describe Type of Treatment or Testing
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Doctor
Trealment
18 Enter an " X in the appropriate box:
Has your personal physician or other doctor treated
you since the date in ltem 7?
b
Yes b
No
Go to ltem 19
b Go to ltem 20
Form AA-Id (09-07) Page 3
Doclor
Trealment
(Con11
19 Enter information about each personal physician or other doctor who has treated you.
a Name of Physician
Address of Physician (Street Address, City, State, and ZIP Code)
Dates Treated or Examined
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Describe Type of Treatment or Examination
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Address of Phvsician (Street Address, Citv. State, and ZIP Code)
b Name of Physician
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Telephone Number (Include Area Code)
Patient Number
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Dates Treated or Examined (
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Describe Type of Treatment or Examination
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Railroad
Employer
Examinaton
20 Enter an "X" in the appropriate box:
Yes b
Has your railroad employer referred you to a medical sour?
for examination or treatment since the date in Item 7?
O N o
Go to ltem 21
b GotolM22
2 1EnteGformation about this examination or treatment.
Address of Source (Street Address. C i . State. and ZIP Codel
Name of Medical Source
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Enter an "X" in the appropriate box:
Inpatient
Outpatient
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Form AA-Id
(09-07)
Page 4
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Telephone Number (IncludeArea Code)
Patient Number
Dates Treated or Examined
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Describe Type of Treatment or Examination
Railroad
22 Enter an "X" in the appropriate box:
Employer
Have you been medically disqualified for work by your employer?
Examination
(ant)
Yes b Go to Note then Item 23
NO
b
Go to ltem 23
Note: I f answered Yes," you must submit a copy of the DisqualificationNotice.
Aclivlly
23 Enter an " X in the appropriate box:
Restriclion
Has a medical doctor restricted your daily activities since the
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date in ltem 7?
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24 Enter the name of the medical doctor who imposed
the restriction.
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25 Enter the date the restriction began.
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5 Yes
b
Go to ltem 24
NO b Go to ltem 28
Year
Month
26 Describe the restriction.
27 Enter the address of the medical doctor in Item 24 if
it has not previously been entered in Items 17, 19, or 21.
Address (Street Address, City, State, and ZIP Code)
b
Medication 28 Enter an 'X" in the appropriate box:
Yes b Go to Item 29
No b Go to Section 5
Has medication been prescribed for you?
29 Enter from the prescription labels the following informationfor all medications prescribed for you:
Name or type of medication, dosage, and frequency. (For example, Penicillin, 1.5 gram tablet, 3 times a day.)
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NamelType
Dosage (Grams, Number of Pills. Etc.)
Frequency
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Information About Your Education And Training
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Schooling 3 0 a Enter the highest grade of school you completed.
b Enter the last year that you attended s
b
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Yes b Go to ltem 32
31 Enter an " X in the appropriate box:
Have you attended technical school?
32
Describe the type of technical school you attended.
33
Enter an "X" in the appropriate box:
Have you r.eceived a certification or license from the technical
school you attended?
b
Enter an " X in the appropriate box:
Is the certification or license you received currently valid?
b
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NO
b
Go to ltem 35
fl Yes
b
Go to Item 34
b
Go to Item 35
No
Yes
No
Form AA-I d (09-07) Page 5
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35 Enter an 'X. in the appropriate box:
Did you receive specialized training?
Schooling
(Cont)
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Yes b
No
Go to Item 36
b Go to Section 6
36 Enter the type of specialized training you received and the period of time you received it.
Dates
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37 Enter an 'X" in the appropriate box:
Have you used any of this training in your work?
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Yes b
No
Go to Item 38,
F Go to Section 6
3 8 Describe when and how you have used this training in your work.
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Information About Your Daily Activities
39 Check the one box after each activity listed below that best describes your ability to do that activity.
EASY I can easily do the activity.
HARD - I can do the activity with difficulty or with help.
NOT AT ALL - I cannot do the activity even with help.
~ctivres
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Not
Hard At All
Activity
Explanation - Explain each "HARD" answer-
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Sitting
1
Standing
1
Eating
(
Bathing
ti
.m
[3
O r (
Dressing (Tying Shoes,
Combing Hair, etc.)
1
Other Bodily Needs
C@
nb
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Indoor Chores (Meal
Cleaning, etc.)
Outdoor Chores
(Shopping, Yardwork, etc.)
1 Driving a Motor Vehicle
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Using Public Transportation
Conducting Personal Business
T a n g to a n Dealing
with Other People)
Reading English (For example,
newspapers and magazines)
Writing English (For example,
Form AA-ld (09-07) Page 6
0
b
1
1
40 Enter any additional-informationthat describes your daily activities during a normal day (i.e., a typical day from the time
you get up until you go to bed).
Achilies
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InformationAbout Your Work And Earnings
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Workforan 41 Enter an " X in the appropriate box:
Employer
Have you worked for pay for a railroad or nonrailroad employer in
Last 12
the last 12 months? (Do not include any self-employment.)
MonUls
Yes b
Go to Item 42
No
Go to Hem 44
b
42 Enter your earnings before any deductions for each month you have already worked this year. Then starting with the
current month, enter your expected gross earnings for this month and each remaining month this year.
January
February
March
April
May
June
.luly
August
September
October
November
December
43 Enter your earnings before any deductions for each month last year.
Monlhs
January
February
March
April
May
June
July
August
September
October
November
December
44 Enter an "X" in the appropriate box:
Do you expect to work during the next 12 months?
(Include self-employment, if any.)
45 Enter the name and address of the person or
company for whom you expect to work.
(If self-employed, enter "Self.")
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Yes b
Go to Item 45
No
Go to Section 8
b
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46 Enter the date(s) you expect to work.
(For example: "June and July";
Indefinitely starting 11-89; etc.)
47 Enter the gross amount you expect to earn.
(If you are self-employed, enter the
net amount.)
b
Form AA-ld (09-07)Page 7
General Information
Filing
AA-1
48 Enter an "X" in the appropriate box:
Are you filing Form AA-1 at this time?
Self49 Enter an "X" in the appropriate box:
Employmen
Have you been self-employed in the last 12 months?
( NOTE:
Workeh
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Yes
No
b Go to ltem 54
b Go to ltem 49
Yes b
NO
b
Go to Note and Item 50
Go l o ltem 50
If answered 'Yes," also complete and return to the RRB Form AA-4, Self Employment QuesUonnaire.
50 Enter an "X" in the appropriate box:
Since the date in ltem 7, have you received, or
expect to receive, worker's compensation payments?
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Yes b
Go to Note and ltem 51
No
Go to ltem 51
b
)
NOTE: Proof of the amount(s) and effective date(s) of your worker's compensation is required.
Public
Diability
Benefils
51 Enter an "X" in the appropriate box:
Since the date in Item 7, have you received, or do you expect to
receive, disability benefits under a Federal, state, or local government plan or law based on employment not covered under the
Social Security Act? (Answer "No" if your benefits are railroad
retirement, social security, Veterans Affairs or welfare benefits.)
.
.
.
.
..
.
.
Yes b
Go to Note and Item 52
No
Go to Item 52
,
NOTE: Proof of the amount(s) and effective date(s) of your public disability is required.
Social
Security
BeneL
52 Enter an "X" in the appropriate box:
Have you filed, or expect to file, for monthly
social security disability benefits or SSI?
53 Enter the social security claim number under which you
have filed or will file.
Criminal
Offense
54 Enter an "X" in the appropriate box:
Within the past 12 months, have you been imprisoned or
given a sentence of confinement due to a conviction for a
criminal offense?
55 Enter the date of the conviction.
56 Enter an "X" in the appropriate box:
Is your disability related to the commission of the criminal offense?
57 Enter the date of the sentence of confinement.
58 Enter the date that confinement began.
59 Enter an "X"in the appropriate box:
Is your d~sabilityrelated to your confinement?
60 Enter an "X" in the appropriate box:
Has the confinement ended?
61 Enter the date confinement ended.
Form Al4-Id (09-07) Page 8
b
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Yes
NO
1Yes
No
,
,
Go to ltem 53
GO
to Item 54
b
Go to Item 55
b
Go to Section 9
Month
Year
Day
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Yes
NO
Month
Day
Month
Day
Year
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Year
Yes
Yes
No
Month
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Go to ltem 61
Go to Section
Day
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Year
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Remarks
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Remarks
62 This section is to be used for the continuation of answers to other items. Be sure to include the item number at
the beginning of the answer you wish to continue. You may also use this space to enter any additional information
that you feel may be important to include.
Form AA-I d (09-07) Page 9
~ e l i n q i s h m e n tOf Rights By Disability Annuity Applicant Only
I authorize the RRB to relinquish any rights I may have to retum to work for a railroad employer, which will affect the
payment of my own or my spouse's annuity. Based on this authorization, my rights will be relinquished when I reach full
retirement age (FRA) or at age 60-FRA if I become entitled to a supplemental annuity or if my spouse becomes entitled to a
spouse's annuity. I understand this authorization remains in effect unless my disability annuity terminates before FRAor
before a supplemental or spouse's annuity becomes payable. My rights will also be relinquished if I am eligible for a reduced
age and service annuity and choose to receive this type of annuity if my disability is denied.
Certification
Certification 63 Enter an "X" in the appropriate box:
Yes t
Will you have a guardian or other representativesign this
application on your behalf'?
NO
Go to Note and ltem 64
t Go to Item 64
NOTE: If answered "Yes," the guardian or other representative of the applicant must sign this application.
That person'must also complete, and retum Form AA-5, Application for Substitution Of Payee.
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64 1 know that if I make a false or fraudulent statement in order to receive benefits from the RRB or if I fail to disclose
earnings or report employment of any kind to the RRB, I am committing a crime which is punishable under Federql law.
I have received booklets, RB-Id, Employee Disability Benefits, and RB-9, Employee and Spouse Events That Must
Be Reported. I understand that I am responsible for reporting any events that would affect my annuity, as explained in
these booklets.
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I ceMy 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 work for any employer, railroad or nonrailroad, or perform any self-employmentwork;
If my condition improves;
If I am confined in a jail, prison, penal institution, or correctional facility due to a conviction for a criminal offense;
If I begin to receive worker's compensation payments (or any other public benefit based on disability),
or if the amount of my payment changes;
If my address changes.
I know that if I am receiving a disability annuity and fail to report work and earnings promptly, I am committing a crime
punishable by Federal law that may result in criminal prosecution andlor penalty deductions in my annuity payments.
Signature
(First Name, Middle Initial,
Last Name)
Year
Date
b
65 If this certification is signed by mark ("X") in ltem 64, two witnesses who know the person signing must sign below,
aivino their full addresses and daytime telephone numbers.
a. Signature of Witness
1
Address (Number and Street)
1
City. State, and ZIP Code
Daytime Telephone Number (include area code)
=(
)
=(
)
b. Signature of Witness
Address (Number and Street)
City, State, and ZIP Code
Daytime Telephone Number (include area code)
Form AA-Id (09-07) Page 10
How To Return Your Application
Before you retum your application, check to make sure that:
b Every question that applies to you has been answered.
b You have entered "unknown" in any answer space for which you were unable to answer a question.
b You have signed and dated the application.
b You have included all the needed proofs listed in the letter you received with this application.
When you received your application, you should also have received a pre-addressed retum 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.
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:
b NEEDED PROOFS
b THE APPLICATION FORM ITSELF
b ADDITIONAL FORMS YOU WERE ASKED TO COMPLETE
/Wake no entries on page 13, 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 a month after you filed
this application,please contact us so we can find out what is causing the delay.
Form AA-Id
(09-07)
Page 11
PAPERWORK REDUCTION AND PRIVACY ACT NOTICE
This notice is given under the Paperwork ReductionAct 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.
1)
2)
3)
4)
The law which allows us to ask for the information;
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;
the reason why the information is requested; and
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 (RRA) 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 or not 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.
Although the information we request is almost never used for any purpose other than the payment of benefits under the RRA,
the RRB does have the authority to release the following information to the indicated individuals, organizations, andlor agencies
without your approval:
1) lnformation may be released to 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 representingyou at your request.
2) lnformation may be released to 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) lnformation may be released to a person who will receive benefits on your behalf if the RRB decided that some medical
condition keeps you from receiving your own beneffis; 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) lnformation (including medical records) may be released to people or organizations who are working for the RRB.
5) lnformation may be released to the U.S. Treasury Department or Postal Service to issue payments and to investigate
lost, forged, or stolen payments.
6) lnformation may be released to 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 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) lnformation may be released to the Social Security Administration, Centers for Medicare 8 Medicaid Services, Pension
Benefit Guarantee Corporation, 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 their organizations and if any previous benefits
were paid incorrectly.
8) lnformation may be released to the Internal Revenue Service or to State and local taxing authorities for figuring your
taxes and for use in audits.
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.
10) lnformation may be released to the General Accounting Office for audits and for collecting overpayments owed to the
RRB or Social Security Administration.
11) lnformation may be released to the U.S. Department of Labor as required by the Federal Coal Mine and Safety Act.
12) lnformation may be released 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.
15) lnformation may be released to Professional Standard Review Organizationsand State Licensing Boards when services
provided by physicians or practitioners suggest unethical or unprofessionalconduct.
We estimate this form takes an average of 35 to 60-minutesper response to complete, induding the time for.reviewingthe
instructions, getting the needed data, and reviewing the completed form. Federal agencies may not conduct'or sponsor, and
respondents are not ,requiredto 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 60611-2092.
The Computer Matching and Privacy Protection Act of 1988 requires the RRB to advise you that information you have provided
may be used, without your consent, in automated matching programs. These matching programs are a computer comparison of
RRB records with records kept by other Federal. State, or local governmental agencies. lnformation from these matching
programs can be used to establish or verify a person's eligibility for federally funded or administered benefit programs and for
repayment of payments or delinquent debts under these programs.
Form AA-ld (09-07) Page 12
Receipt For Your Claim
EmployeeApplicant's Name
RRB Claim Number
Date Claim Received
A
Your application for railroad retirement disability benefits has been received and will be processed as quickly
as possible. If you change your address or if there is some other change that may affect your claim, you or
your representative should report the change. The changes to be reported are listed below. Always give us
your claim number when writing or calling about your claim. If you have any questions about your claim, we
will be glad to help you.
If you need to personally visit one of our field offices, please call for an appointment. You will not be refused
service if you do not have an appointment, but our staff can serve you better when an appointment is made.
Most offices are open to the public from 9:00 AM to 3:30 PM. Monday through Friday.
Always Report These Changes to the RRB
WORK- If you work for any employer, railroad or nonrailroad, or perform any self-employment work.
-
CONDITION If your condition improves.
WORKER'S COMPENSATION (or any other benefit based on disabilily) If you begin to receive worker's compensation payments (or any other public benefit based on disability),
or if the amount of your payment changes.
CRIMINAL OFFENSE - If you are confined in a jail, penal institution, or correctional facility due to a conviction
for a criminal offense.
ADDRESS
- If your address changes.
How To Report Changes
When a change occurs after you are entitled to disability benefits, you should report the change at once. You can make your
reports by telephone, mail, or in person, whichever you prefer.
To report any of the above changes, contact:
Tf
Telephone Number:
(9:00AM - 3:30 PM)
If for some reason you cannot contact that office, you should contact:
b
US RAILROAD RETIREMENT BOARD
844 N RUSH STREET
CHICAGO IL 60611-2092
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F o n AA-ld (09-07) Page 13
| File Type | application/pdf |
| File Modified | 2010-03-29 |
| File Created | 2010-03-29 |