Form AA-1 Application for Employee Annuity

OFFICIALLY FILED

MONTH

YEAR

DAY

OFFICE NUMBER

I
LAST ER

APPLICATION FOR
EMPLOYEE ANNUITY

NEXT-TO -LAST ER
I

APPROVED
I

..... ............. ......................... .......... ........... .. ...................... .............. .............

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APPLICATION NUMBER

DATE CODED

MONTH

I

DAY

YEAR

II

CODED BY
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~

General Instructions
Before you complete this application, be sure to read the booklet RB-I, Age and Service Employee Annuity, which explains
information you will need to answer many of the questions in this application. Also be sure to read the important notices in the
the RB-1 booklet.
Type or print legibly in ink. If you need more space than is provided to answer a question, use Section 21 for this purpose. If
you do not know the answer to a question, print "Unknown" in the space provided for the answer.
g dates, always use numbers. Also, be sure there is one

each box. For example, you would enter

Some items in this application will not apply to you and 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 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.

I

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.
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 missincr, fill it in.

*
*

(Empl
oyee
Identification

I

1 1
2

SOCIAL SECURITY NUMBER

5

I

--

AILING ADDRESS

1 1
I

1

RAILROAD RETIREMENT CLAIM NUMBER

I 3 1 EMPLOYEES NAME
4

(

-A

DAYTIME TELEPHONE NUMBER
I

I

Form AA-1 (@%& Destroy Prior Editions

1 Sex

Marital
Status

m Male
-- a Female

6

Enter an " X in the box that shows
your sex.

7

Enter your name at birth if different from ltem 3.

8

Enter your date of birth.

9

Enter an " X in the box that shows your
current marital status.

-

Never Married

10

Enter your spouse's full name before your marriage. ---,

11

Enter your spouse's date of birth.

12

Enter the date of your marriage.

13

Enter your spouse's social security number.
If none, enter "To Be Submitted."

Marriage

>

1 15 1

+

11

Go to Item 14

Year

Month

Enter an " X in the appropriate box:
I was previously married. (Answer "No" if your only
previous marriage was an earlier marriage to your
current spouse.)

14
Marriage
History

Go to Item 16
Go to Item 10

m Married or Separated
m Other
Day

Year

I

l

l

m Yes + Go to ltem 15

a

NO + GO to Item 16

Give the following information for your previous marriage(s). Use Section 21 if you have more than one previous
marriage.
(i) MARRIAGE BEGAN

a

DATE

CITY & STATE

I

(iii) MARRIAGE ENDED

(ii) NAME OF FORMER
SPOUSE

REASON

DATE

CITY & STATE

QDEATHQDIVORCE

O ANNULMENT

a

-

OTHER Explain in
Section 21

(iv) Enter your former spouse's date of birth. >

Month

Enter the Social Security Number of former spouse
I I (v) shown
in Section 15a(ii).
>
b

I

-

I

Day

I

I

I

I

I

Year

I

l

l

If unknown,
'
enter
I
unknown and
I
complete Item 15b.

Enter your former spouse's
Place of birth
Father's name

I
1 Children

Mother's maiden name

I

I

Please read Part I of the RB-1 booklet for an explanation of family members who could qualify you for the
Special Guaranty Computation.
Enter an " X in the appropriate box:
I have children who are unmarried and meet any of the
>
following conditions:
(1) Under age 18.
(2) Age 18 through 19 and attending elementary or
secondarv school full-time.
(3) Age 18 o; older with a continuing disability that began
before age 22 and prevents any kind of employment.

/

<

a

Note: I f you have a child that meets the disability
Application for Determination o f Child's ~isability.

Enter in each box the number
of children who meet each condition.

Form AA-1

m Yes + Go to Note and ltern 17

(@-wPage 2

1m

a
a

P

+ Gotoltem18

No

R
Under age 18.
Age 18 through 19 and attending elementary
or secondary school full-time.
Age 18 or older with a continuing disability
that began before age 22 and prevents any
kind of em~lovment.

Do not complete Item 18 if you have never married; go to ltem 19.
Garnishment 18
or
Property
Settlement

Enter an " X in the appropriate box:
a. The RRB has been furnished with an order to enforce either
my child support or alimony obligation, or to pay part of my
present or future railroad retirement benefit to a spouse or
former spouse as a part of a property settlement in a divorce
or legal separation proceeding. (NOTE: Reference to
pension rights may be found in the property settlement.) +

I I

I
Criminal
lowenre

19

1

1 I

0 Yes + Go to ltem 18b
0 No + Go t o ltem 19

a

b. Which situation applies?
Enter an " X in the appropriate box:
Within the past 12 months, I have been imprisoned or given a
sentence of confinement due to a conviction for a criminal
offense.
>

20

Enter the date of the conviction.

21

Enter the date of the sentence of confinement.

Child Support or Alimony
Property Settlement

1

0 Yes + Go to ltem 20
0 No -+GOto Section 4

1

-

Month

Year

Day

II

II

Month

Day

I

I

I1

II

Year

p
p
p

22

Enter the date that confinement began. P

I
Yes

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

[7 No

I

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I

l

l

+ Go to Item 24
+ Go to Section 4
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Information About Type of Annuity

I

i

Please read Part I of the RB-I booklet for information about age and service annuities. Also read the RB-Id booklet if you are
applying for a disability annuity.

a
a
a
a

Type of
Annuity

1 25 1

1

Enter an " X in the box that shows the type
..
of annuity you are filing for.

*

I

FULL AGE ANNUITY
FULL 60130 AGE ANNUITY
DISABILITY ANNUITY
REDUCED AGE ANNUITY- LESS
THAN 30 YRS' SERVICE

Section 5

0 Yes
0 No

Enter an " X in the appropriate box:
I am eligible for and will accept a reduced age annuity
if I am not eligible for a full age or a disability annuity. +

Please read Part I of the RB-I booklet for information about military service. Creditable military service is used to determine, in
part, your annuity eligibility. It can also be used in your annuity computation.

-

Military
Service

Enter an " X in the appropriate box:
I was in active military service, such as the Army, Navy,
Air Force or Marines, of the United States.

0 Yes + Go to Note and ltem 28
0 No + Go to Section 6

Note: If answered "Yes,"you must submif proof of your milifary service, such as your discharge
certificafe or separafion papers, as explained in fhe RB-I booklef.

I

I

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

0 Yes + Go to ltem 29
0 No + Go to ltem 30

Enter an "X" in the appropriate box:
I had nonrailroad earnings after leaving the military service
stated in ltem 28 and before returning to the railroad. ---t

0 Yes
0 No
I

I

Form AA-1 @l
Page
*)3

--

30 Enter an 'X' in the appropriate box:
I have filed, or plan to file, a claim for monthly benefitswith another
Benefits

Year

33

6the claim number of the monthly benefit you have already filed for.
Information About Your Railroad Work

Please read Part I of the RB-1 booklet to find out what railroad work is creditable. Creditable railroad work is used to
determine your annuity eligibility and is also used in the annuity computation.

34

Enter an " X in the appropriate box:

17 Yes

-

/

Last Railroad
Employment

Enter the name of the railroad company or railroad
labor organization that last employed you.

S

31

Enter your payroll name and identification number for
that employer.
Enter your last job title for that employer.

W

+

*

Enter your last division or department and its location.

Other
Railroad

-+ Go to Note and Item 36

+

3q

Enter the dates you worked for that employer.
(If your railroad employment has not ended,
enter the last date you will work for that
employer in the " T O date.)

35

Enter the date you gave up or will give up your seniority
Month
lights and all other rights to work for the employer shown
In ltem 36. (Make no entry if you have not given up your
rights because you are filing for a disability annuity.) +

>

iJ Yes

@ Enter an " X in the appropriate box:

Day

Year

-+ Go to ltem

Enter the name of that employer.

ttb Enter your payroll name and identification number for

%g that employer.
#
L

Form AA-1

IkI

Enter your last job title for that employer.

M-m Page 4

>

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Other

46 Print your last division or department and its
Railroad
Employment @ location for that employer.
(Cont.)
49 Enter the dates you worked for that employer.
(If your railroad employment has not ended,
enter the last date you will work for that
employer in the "TO" date.)

*
FROM
Month Day

41

Railroad
~

i

Month

Day

1

1

(Make no entry if you have not given up your rights because
you are filing for a disability annuity.)
>

M Enter an " X in the appropriate box:
h
43

~

Year

>

4 8 Enter the date you gave up or will give up your seniority rights
and all other rights to work for the employer shown in ltem 43.

JL

TO
Month Day

Year

a
a

I~still ~have seniority or other rights to work for a

>

not listed in It

Year

1

1

1

Yes

+ Go to ltem

No

+ Go to Section 7

of any employer indicated
whom you still have rights
k.

*

lnfohwdon About Pay For Time Lost
Please read Part II of the RB-I booklet to find out what payments can be creditable as pay for time lost.
I

Pay For
Time Lost

I

54

v5

I

Enter an " X in the appropriate box:
I received or expect to receive pay for
time lost from my last railroad employer.

a
a

Yes + Go to Note and lt&m&
No

+

Go to Section 8

Note: If answered "Yes," and you received an injury settlement or elected to receive "dismissal pay,"
enclose a copy of your settlement or election with your application. If your case is still pending, briefly
explain it in Section 21.

TO
FROM
Year
Month
Month
Day
- Day -

S Enter the dates for which
these payments were made or
~)(p

Year

will be made.

Information About Railroad Sick Pay

I

Please read Part ll of the RB-I booklet to find out when sick payments can be creditable to Tier I.
road Sick

Enter an "X in the appropriate box:
I received or expect to receive sick pay
under a railroad wage continuation plan
(other than my own regular salary) that
was established through a company policy
or labor agreement and this pay was for a
period after the actual day I last worked.
(Answer "No" if you were carried on the
payroll and just received your regular
salary.)

,!@
1

a

Enter the name of the sick pay plan, if known.

b

Enter the dates for which these payments were made or will be made for
up to 6 months after your actual day

1

last worked.

Yes

a

No

+ Go to Ite
+ Go to Section 9

>

FROM
~ o n t h Day
l

(

Year

TO
~ o n t h Day
l

*
Form AA-1

I

Year

(J@mPage 5

Information About Your Nonrailroad Work
I

Please read Part IV of the R B - I booklet, which explains how Last Pre-Retirement Nonrailroad Employment, self-employment,
and other earnings affect your annuity. Also read Part I of the booklet which explains "Current Connection."
Nonrailroad
Work

Enter an " X in the appropriate box:
I worked for pay outside the railroad industry
either during the last 6 months I worked in the
railroad industry or after I left the railroad industry.
(Do not include self-employment. Include any
employment for an incorporated business which
you own or public service. If you are a Canadian
citizen or permanent resident, include employment
in Canada for the U.S. railroad employer performed
January 1, 1983, or later.)

I I

CII Yes + Go to Note and ltem
J-!

+ Go to ltem

No

*

\

f ~ o t e : If you had Last Pre-Retirement Nonrailmad Empldyment (LPE) affer your annuity would begin,
complete Form G-19F, Earnings Information Request, only when one o f the following applies:
(1) The annuity beginning date (ABD) is before January Iof this year or
(2) the ABD is January 1, or later, of this year, and you ceased working in LPE after the ABD month/

\

I

Most Recent !3€f
Nonrailroad 50
Work

61

Enter the name and address of your current or most
recent nonrailroad employer.

1

&

I

.I -

b

1

I

t

tP

E~E~EFX~:~~TOZ?~:$OMY~*
for that employer.

+

Enter your average monthly salary for that employer.

4% (SHOW DOLLARS ONLY)
83

a
51(.
Next Most
Recent
Nonrailroad
Work

f$

1%

FROM

Enter the dates you worked for that
employer. (If you have not set the date
you expect to stop working, leave the
"TO" date blank and check the box
-A
"I am still working.")
/LA \

TO

Month Day

a

Year

Month Day

Year

I am still working

Enter an " X in the appropr
The employer named in lte
employer or a Federal Gov
listed in Chapter 5 of the R B - I booklet. P
Enter the name and address of your next most
recent nonrailroad employer during your last 6
months in the railroad industry or after you left
the railroad industry.
o
r-*e
rE
n
t

If none, enter "NONE" and go to

*

that employer. P

nter your average monthly salary for that employer.
(SHOW DOLLARS ONLY)
(5a Enter the dates you worked for that
employer. (If you have not set the date
you expect to stop working, leave the
"TO" date blank and check the box
"I am still working.")
cJ\

FROM
Month Day

68
63

fl

Enter an " X in the appropr
The employer named in Ite
ither a seasonal
employer or a Federal Government agency that is
listed in Chapter 5 of the R B - I booklet.

=arm AA-1 W-m

Page 6

*

I am still working

J- I

*

Year

cl

Yes
No
-

-

TO
Month Day

Year

I

)

If you are employed and your business is incorporated, an
complete2 If your business is not incorporated, answer It

Self-

Employment

-W fMD
&?

60

I I

Enter an " X in the appropriate box:
I was self-employed during my last
6 months in the railroad industry or
after I left the railroad industry.

a Yes +
No

Go
:ot

and I

+ Go to Section 10

t

e

m

u

I

Note: If answered "Yes, " complete and return to the RRB, Form AA-4 Self-Employment and
Substantial Service Questionnaire.
I

Yes

Enter an " X in the appropriate box:
I am still self-employed.

1J
%j

I -

-1
I

I

1 1

1

0 NO + Go to Item&

Mot,lTH

Enter the date you were last self-employed.

+ Go to Section 10

,

YEAR

i
3
;

,

,

I

I

l

I

I

l

I

Deemed Current Connection

Please read Part I of the RB-I booklet for an explanation of a deemed current connection.

JM Enter an " X in the appropriate box:
I have at least 25 years of railroad service

Deemed
Current
Connection

13

railroad employment
break my current

$8 Enter an " X in the appropriate box:

*

-

I was separated from my last railroad
employer involuntarily and through no fault
of my own on or after October I, 1975.

Enter an " X in the appropriate box:
I was on furlough, leave of absence or
absent because of injury status with my
last railroad employer on October 1, 1975,
and was never called back to work.

jX

b5

Enter an " X in the appropriate box:
I declined an offer to work in the railroad
industry in the same "class or craft" as my
last railroad job.

0 Yes
0 No

+ Go to Ite

0 Yes
0 No

+ GO to lte

+ Go to Section 11

+ Go to lte

0 No + Go to Section 11
+

a Yes +
a No +

Go to Section 11
Go to Note and Section 11

,"submit the required proofs
ote: If you answered either Ite
soon as possible. This will preserve your rights under the deemed current connection provisions. The
required proofs are explained in the RB-I booklet.
I

1

I

Information About When Your Annuity Will Begin
Please read Part II of the RB-1 booklet for an explanation of an annuity beginning date.
Annuity
Beginning
Date

id Enter an "X in the appropriate box:
I want my annuity to begin on the
67~earllest
.
date permitted by law.

-

Enter the date you want your annuity
to begin.

-

a Yes +

Go to Section

0 No

Go to ,ten&

Month

Day

Year

Form AA-1

m--)

Page

lnforma$miP+bout Your Earnings
Before answering Ite
and service annuity.

please read Part IV of the R B - I booklet to find out how earnings can affect an age
empt amounts, refer to Form G-77a, How Work Affects Your Railroad

Retirement Benefits.

If you are applying for a disabili
annuity is denied, answer Items
Earn~ngs
Last 'fear

but are eligible for and would accept a reduced age annuity if the disability
hich apply to the reduced age annuity. Otherwise, go to Section 13.

0 Yes + Go to Ite

Enter an " X in the appropriate box:
W
.

64

I expect my annuity to begin before

m

January 1 of this year.
(Year)

74f Enter an " X in the appropriate box:
My total earnings from all employment last year were
70 more
than the annual earnings exempt amount. (If all your
earnings are from only railroad employment before your
date last worked, answer "No.")

NO

+ GO to lte

m Yes + Go to Ite
m No + Go to Ite

*

fl Enter your total earnings for last year.

71

(SHOW DOLLARS ONLY)

48 Enter an " X in the appropriate box:

-

I earned more than the monthly earnings exempt amount
in employment for hire, or performed substantial services
in self-employment in every month last year.
Enter an " X next to each month last year
in which you did not earn more than the monthly
earnings exempt amount or perform substantial
services in self-employment.

Earnings
This Year

m No

J-I

Form AA-1

I

No

+ Go to Ite

Enter an " X next to each month this year in which
you did not earn, or do not expect to earn, more than
the monthly earnings exempt amount or perform
substantial services in self-employment.

*

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

*

(#(-m
Page 8
I

+ Go to lte

m Yes + Go to Ite

n

0 Yes + GOto I

Enter an " X in the appropriate box:
I expect my total earnings from all employment next year to
be more than this year's annual earnings exempt amount. -+
I

m

+

Enter an " X in the appropriate box:
I expect to earn more than the monthly earnings exempt
amount in employment for hire, or to perform substantial
services in self-employment in every month this year. --,

c

e

0 Yes + Go to lte

*

Enter the total amount you expect to earn this year.

t

*

Enter an " X in the appropriate box:
I expect my total earnings from all employment this year to
be more than the annual earnings exempt amount. (If all
your earnings are from only railroad employment before
your date last worked, answer "No.")
(SHOW DOLLARS ONLY)

m Yes + Go to i

NO
I

)00"

t

e

W

Section 13
I

Earnings
Next Year
(Cont.)

I

Enter the total amount that you expect to
earn next year. (SHOW DOLLARS ONLY)

1

Enter an " X next to each of the first four
months of next year in which you expect to
earn less than this year's monthly earnings
exempt amount.

I

I

-

I

I

>

lnformation About Social Security Benefits
Please read Part V of the RB-I booklet to see how this application can protect your rights to social security benefits, and
to see what effect your receipt of social security benefits will have upon your railroad retirement annuity.
Enter an " X in the appropriate box:
I also want this application used to protect my filing
date for social security benefits. (Answer "Yes" only
if you are age 62 or older, disabled, or otherwise
eligible for social security old age, disability, or
survivor benefits and you have not filed an application for such benefits.)

Social
Security
Filing Date

m Yes
0 No

*

-

m Yes + Go to Item
m No + Go to Section 14

Enter an " X in the appropriate box:
I have filed, or plan to file within the next 90 days,
an application for social security benefits.

1@

for these social security benefits.

*

Enter an "X" in the appropriate box:
I have received my first social security
payment.

A6

I

-

I

l

i

1

I

$
L

m Yes + Go to Ite

-

Enter the social security number of the person on whose
earnings your social security benefits are based.
Enter the name of the person on whose earnings your
social security benefits are based.
I

i

I

Enter an " X in the appropriate box:
All or part of my social security benefits described above are
based on the earnings of someone other than myself. +

,

Year

I

0 Yes + Go to lte
0 No + Go to lte

>

Enter the current total monthly amount of your
social security benefits (before reduction for
work or Medicare premiums).

81,

I

1 Month

961 Enter the date you became. or will become. eligible

0
I

+

I

lnformation About Non-Covered Service Pension
Please read Part V of the RB-I booklet for information concerning non-covered service pensions. Complete Items 96 and 97
only if your date of birth is January 2, 1924, or later. Otherwise, go to Section 15.

4"1

Non-Covered
Service
Pension

0

1
41

Enter an "Xu in the appropriate box:
I am receiving or expect to receive a pension or annuity
or lump sum in excess of contributions based on any
work after 1956 not covered by social security or
railroad retirement.
Enter an "X" in the appropriate box:
The beginning date of the pension or
annuity is January 1, 1986, or later.

0 Yes + Go to ,
No

*

t

e

a

+ Go to Section 15

m Yes + Go to Note and Section 15
*

0 No + Go to Section 15
I

Note: If answered "Yes," complete Form G-209, Employee Non-Covered Service Pension

-1
11

Information About Other Railroad Retirement Annuity
Please read Part V of the RB-1 booklet for an explanation of the effect of your employee annuity on any other railroad
retirement anlnuity.

Other
Railroad
Annuity

1

I

86 Enter an “ X in the appropriate box:

4%

94~
I

Enter the full name of that other person.

19

I

1

II

-

I have filed within the last 30 days, or intend to file
within the next 90 days, for an annuity based on
another person's railroad earnings record.

II

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

C]I
C]I

+ Go to i t e m s

No

+ Go to Section 16

Prefix

I

93

Yes

If only six numbers, enter here
,

*1

I

I

I

,

I

I

,

I

I

I

I

I

I

I

I

,
I

,

/

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Information About Supplemental Annuity

1

1

Please read Part I of the RB-1 booklet for an explanation of what is required to be eligible for a supplemental annuity.

445

Supplemental 1
Annuity
Eligibility

1

Enter an " X in the appropriate box:
I am now, or will be, eligible for a supplemental annuity
from the Railroad Retirement Board (before reduction
for a company pension).

-

C]I
C]I

Yes

+ GO to lte

No

+ Go to Section 17

C]I Yes + Go to Ite

@
@

Enter an "Xuin the box which most accurately
applies to the job or position which qualified
you for this pension.

Enter the date your pension began, or will begin, or
the date of your lump-sum pension payment.

*

C]I
C]I
C]I

Salaried
Non-Agreement
Agreement

5 Other
Month

Year

Day

I

I

I

-

If none, enter "NONE" and go to ltem/c@@

C]I

Salaried

5 Non-Agreement
you for this pension.

C]I
C]I

Agreement
Other

Month

C]I

I

Yes

5 No

Day

I

Year

1

)

1

I

Information About Medicare

I

Complete this section only if you are 64 years and 5 months of age or older.
Please read Part VI of the RB-I booklet for an explanation of the Medicare program.

-

" X in the appropriate box:
I have a Medicare card that shows entitlement
to Medicare medical insurance (Part B).

Enrollment

I4-f Enter your Medicare claim number.
(If this is a railroad retirement filing, enter the prefix. If this
IS a social security filing, enter the suffix).
ll?! Enter an " X in the appropriate box:
I have filed for Part B within the last
j o b three
months.
>
Enter the social security number or railroad retirement
claim number under which you filed.
(If this is a railroad retirement filing, enter the prefix. If
this is a social security filing, enter the suffix.)
Date of filing

C1 Yes + Go to Ite
C1
lte
+

5

Enter an " X in the appropriate box:
I wish to enroll in Part B.

Go to Section 18

C1 Yes + Go to Ite
C1 No + Go to lte
Month

'

@
JID

Ill

*

1

-------

I

The
$I&
' beginning and ending i
112. dates of my EGHP cover- EGHP Beginning Date +
i
age and the date last
worked in the employment EGHP Ending Date
which qualified me for
j
EGHP coverage are:
Date Employment Stopped +

3

-

Enter an "X" in the appropriate box:
a. I am enrolling in Part B while either still covered by
an EGHP or during the first full month after my
EGHP coverage.
b. I am requesting a Part B effective date of

I

+

Yes + If you are under age 65 years
and 4 months, go to Section 18.
If you are older than age 65 years and 3
months, go to ltem 115.
No + I understand that I elected not to
enroll in Part B and that the premium rate
may be higher if I do enroll later in Part B.
Go to Section 18.

C1 Yes + Go to Ite
C1 No + Go to lte

If applicable. the date employment will stop for the
person whose employment qualifies me for EGHP
coverage is:

$l#'Enter an " X in the appropriate box:
I wish to enroll in a special enrollment period.
J

1

1

-

:

Year

I

I

Enter an "X" in the appropriate box:
I was previously covered by an EGHP based on my
own or my spouse's current employment.
The beginning date of my EGHP coverage is:

I

Go to Section 18

>

Enter an " X in the appropriate box:
I am currently covered by an employer group health
plan (EGHP) based on my own or my spouse's
current employment.

Day

I

C1

p.8

I

s

Dyes

+ Got01

C1

+

Month

Day

Month

Day

I

I

I

I

Month

Day

Go to
Year

I

I

-

I

\

Year

/

r
JYes + Go to
C1 No + Go to lte
Yes

[] No

+ Go to ltem
+ Go to Section 18

Month

Day

I

I

Year

1

I

I

Goto
Section 18

1

Disability Medicare
If you are filing for a disability annuity, go to Section 19.
If you are less than 64 years and 5 months of age, and you are not filing for a disability annuity, you may be entitled to
Medicare benefits based on your being totally disabled for all employment and being entitled to an annuity before age 63.
If your entitlement begins after age 63, you may not be entitled to early Medicare, but you may be entitled to have your Tier I
benefit treated as a social security benefit for taxation purposes. See Form TB-85, Information About the Taxation of
Railroad Retirement Annuities, Part 6, Section 6A. ,
Disability
Medicare

"I

Enter an "X" in the appropriate box:
expect my annuity to begin before I
:each age 63.

'I'

Enter an " X in the appropriate box:
I am totally disabled for work in all
regular employment.

+

*

m Yes -+Go to Note and Section 19
0 No

-+ Go to Section I 9

Note: If answered "Yes," complete and return Form AA-Id, Application for Determination
of Employee's Disability, to apply for Medicare based on disability.
I

I

m a t i o n About You If You Are Disabled
LY if you are applying for a disability annuity. Otherwise, go to Section 20. If you are applying
complete and return Form AA-Id, Application for Determination of Employee's Disability.

I

YOUare asked about your children to determine if you are entitled to a special annuity computation.
Please read Part V of the RB-I booklet for an explanation of worker's compensation benefits and public disability benefits.

Child Living
With You

Enter an " X in the appropriate box:
After 1950 1 had living with me at least
one of my own or my spouse's children,
who was under age 3.
Enter an " X in the appropriate box:
Since my disability began, I have
received, or expect to receive,
worker's compensation benefits.

1
Public
Disability
Benefits

m Yes
* m No
*

m Yes -+ Go to Note
m No -+ Go to Item

(Note:
answered Yes,proof of the amount(s1 and effective date(s) of your worker3
compensation benefit is required.

Enter an " X in the appropriate box:
Since my disability began, I have
received, or expect to receive, disability
benefits under a Federal, state, or local
government plan or law.
(Answer "No" if your benefits are social
security, veterans affairs, or welfare.)

m Yes -+ Go to Note and Section 20
No -+ Go to Section 20

*

Note: If answered "Yes,"proof of the amount(s) and effective date(s) of your public disability
benefit is required.

Form AA-1

(m-rn

Page 12

1

kmnmm;r

Direct Deposit
h

-

1

Please read Part VII of the RB-1 booklet for an explanation of Direct Deposit.

f

Benefits are generally paid by Direct Deposit to your bank, savings and loan, credit union, or o er financial institution.
To provide the information we need to correctly deposit your payments, attach a voided perso I c ck and go to
Section 21. or call your financial institution for the information you need to complete Items &If
have a bank account, or receiving your payments by Direct Deposit would cause you a hardship go to Ite
Enter the name of your financial institution.
l:~it

1
122

-

Enter the telephone number of your
financial institution.

Area Code

I

Telephone Number

>

I

Enter the routing transit number of your financial institution.

A
d

Enter your account number.

Itf

-

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

125

-

,

m Checking
m Savings
Go to Section 21

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

I

*

m
I

Remarks
I

I

Remarks

133 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.

@

I

Form AA-1 ()@@ Page 13

-1

-

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

Certification

a
a

*

YES + Go to
NO + Goto

Note: If answered "Yes," your guardian or other representative must sign this application. That
person must also complete and return Form AA-5, Application for Substitution of Payee.

4
Iz4

I I

1

I

II II

I

I 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 booklets, RB-1, Age
gnd Service Employee Annuity and R k O , Employee and Spouse Annuities--Events That Must Be Reported.
I understand that I am responsible for reporting events that would affect my annuity as explained in these booklets.
I certify that the information I gave the RRB on this application is true to the best of my knowledge.
I agree to immediately notify the RRB:
IF benefits I receive directly from SSA are adjusted for a
reason other than normal cost-of-living
- increases.

IF I begin to receive a pension based on earnings that
are not covered by the Social Security Administration
(SSA) or the R R ~

IF my address changes.

IF I begin to receive benefits directly from SSA.

IF I am confined in a jail, prison, penal institution, or correctional facility due to a conviction for a criminal offense.

IF I am disabled and begin to receive worker's
compensation or public disability benefits.

-

IF I earn more than the annual earninas exempt amount.

IF I am entitled to a
annuity from the RRB
and receive a lump-sum pension payment or begin to
receive a monthly pension from my railroad employer.
IF I am entitled to a vested dual benefit and begin to
receive a benefit based on military service performed
entirely before 1957.
IF I go to work for a railroad or railroad labor organization,
or return to work in any capacity in the railroad industry.

IF ( perform work, including self-employment, for a
family owned, controlled or managed business,
includina a business operated. manaaed or owned
by me, family member, friend or cl&e associate,
whether for pay or not, and without regard to how
the business is organized (e.g., sole proprietorship,
corporationl LLC, etc.).
IF my spouse who is receiving a benefit dies, or our
marriage ends in divorce or annulment.
IF a qualifying child marries or leaves my custody or
residence.
IF I become a corporate officer of, own, or operate a
corporation (including a corporation owned by a family
member or friend) whether for pay or not.

nd there is a change in a date.

IF I receive anything of value in lieu of salary or wages for
any work that I performed.

hs after the date(s)
Also, if I am cover

gs restriction provisions of the Railroad Retirement Act, I have received and reviewed
nt Benefits. Failure to report any of the above events or other
events that may affect my annuity may result in a penalty deduction from my annuity, criminal andlor civil prosecution.

SIGNATURE
(First Name, Middle Initial,
Last Name)
Month

I

Day

I

Year

DATE

a. Signature of Witness

I

Address (Number and Street)

Address (Number and Street)

City, State, ZIP Code

City, State, ZIP Code

Area Code Telephone Number
Form AA-I

b. Signature of Witness

(m-m

Page 14

Area Code

Telephone Number

I
I

Before you return your application, check to make sure that:
Every question that applies to you has been answered.

*

You have entered "unknown" in any answer space for which you were unable to answer a
question.

*

You have signed and dated the application.

*

You have included all the needed proofs listed in the letter you received with this application.

When you received your 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 serving your location. No matter whichenvelope 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:

*

needed proofs

*

the application form itself

*

additional forms you were asked to complete

Note: After the RRB receives your application, a receipt form with information about your claim
will be sent to you. When you receive it, you will know that the RRB has received your application and has started the work needed to determine if you are entitled to benefits. If you do not
receive the receipt within two weeks after you have filed this application, please contact us so
we can find out what is causing the delay.

I

Form AA-1

1

m-)$U

Page .