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pdfForm Approved
OMB 3220-0002
United States of America
Ra~lroadRetirement Board
APPLICATION SUMMARY and CERTIFICATION
RRB Claim Number
Name
Social Security Number
The following information was either supplied by or verified by you in support of your
application for an (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 tlie surnniary to
the RRB.
Military Service
1 I was not in active military service after September 7, 1939.
2
1 was in active military service after September 7, 1939.
Recent Employment
3 1 did not work for an en-~ployeroutside the railroad industry in the last 6 months or
since leaving the railroad industry.
4
1 worked for the following employers outside the railroad industry in the last 6 months
or since leaving the railroad industry.
(Company Name)
(Company Name)
(Company Name)
5
1 worked for the following employers as a seasonal employee:
(Company Name)
(Company Name)
(Company Name)
6
from 99/99/9999 to 99/99/9999
from 99/99/9999 to 99/99/9999
from 99/99/9999 to 99/99/9999
from 99/99/9999 to 99/99/9999
from 99/99/9999 to 99/99/9999
from 99/99/9999 to 99/99/9999
1 was self-employed during the last 12 months.
Railroad Err~ployment
7 You have a current connection with the railroad industry.
8
A current connection with the railroad industry is "deemed" because you:
RRB Form AA-I cert (xx-xx)
32948 64790 22000 06051 32704
Page 1
United States of America
Railroad Retirement Board
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2
3
9
Form Approved
OMB 3220-0002
Had at least 25 years of railroad service, and
"lnvoluntarily and without fault" stopped working for the railroad on or after
October 1, 1975 and was never called back to work for the railroad eniployer,
and
Did not decline an offer from a railroad err~ployerto return to a job in the same
"class or craft" as the last railroad job.
You do not have a current connection with the railroad industry.
10 1 have worked for the following railroad or other employer in the railroad industry.
Railroad Name
Date Last Worked
Date Rights Relinquished
Name and Address
Date of Birth
Daytime Telephone Number
Type of Application Filed
11 I am applying for a benefit based on my age and railroad service.
12 1 am applying for a benefit based on being disabled.
13 You have requested that any payment due you be sent to the following bank
account:
Bank Name
Routing Number
Account Number
Account Type
14 You have requested that any payment due you be sent to the address shown above.
Marriages
15
1 have never been married.
16
1 am curre~itlymarried.
17
1 was previously married.
RRB Form AA-lcert (xx-xx)
32948 64790 22000 06051 32704
Page 2
United States of America
Railroad Retirement Board
Form Approved
OMB 3220-0002
Family
18 1 have a child or children who are unmarried and under age 18.
19 1 have a child or children who are unmarried and age 18 through 19 and attending
elementary or secondary scliool full-time.
20 1 have a child or children who are unmarried and age 18 or older with a disability that
began before age 22.
21 1 do not have unmarried qualifying children.
Other Government Benefits
22
1 have filed or plan to file in the next three months for Social Security benefits on my
own account.
23
1 have filed or plan to file in the next three months for Social Security benefits on the
account of:
Name
Social Security Number
24
1 have not filed nor do I plan to file in the next three months for Social Security
benefits on any account number.
25
1 have not filed nor do I plan to file in the next three months for Social Security
benefits on an additional account number.
26
1 am currently receiving a social security benefit.
27
1 am not receiving a social security benefit.
28
In the past month I have filed or plan to file in the next three months for Railroad
Retirement benefits based on the account of:
Name
Claim Number
29
In the past month I have not filed nor do I plan to file in the next three months for
Railroad Retirement benefits on any other account number.
30
1 am currently receiving a railroad retirement annuity on another account number.
31
1 am receiving or expect to receive a pension or I received a lump-sum payment
RRB Form AA-1cert (xx-m)
32948 64790 22000 06051 32704
Page 3
United States of America
Railroad Retirement Board
Form Approved
OMB 3220-0002
instead of a monthly pension based on my earnings after 1956 from an employer not
covered by Social Security or Railroad Retirement.
32
1 am not receiving nor do I expect to receive a pension or lump-sum payment based
on my earnings after 1956 .from an employer not covered by Social Security or
Railroad Retirement.
Other Benefits
33 1 am receiving a railroad pension from
34
1 expect to receive a railroad pension from
35
1 an1 not receiving and do not expect to receive a pension from a current or former
railroad employer.
36
1 have received or expect to receive workers compensation benefits.
37
1 have not and do not expect to receive workers compensation benefits.
38
1 have received or expect to receive disability benefits under a Federal, state 01- local
goverr~nientplan or law.
39
1 have not and do not expect to receive disability benefits under a Federal, state or
local goverr~nientplan or law.
Miscellaneous Information
40 The RRB has not been furnished with a court order to enforce my child support or
alimony obligation.
41
The RRB has been furnished with a court order to enforce niy child support or
alimony obligation.
42
The RRB has not been furnished with a court order to pay part of my present or
future railroad retirement benefit to a spouse or former spouse as part of a property
settlement in a divorce or legal separation proceeding.
43
The RRB has been furnished with a court order to pay part of my present or future
railroad retirement benefit to a spouse or fornier spouse as part of a property
settlement in a divorce or legal separation proceeding.
44
1 have not received nor do I expect to receive pay for time lost from my last railroad
employer.
RRB Form AA-I cert (xx-xx)
32948 64790 22000 06051 32704
Page 4
United States of America
Railroad Retirement Board
Form Approved
OMB 3220-0002
45
1 have received pay for time lost from my last railroad employer.
46
1 expect to receive pay for time lost from my last railroad employer.
47
1 have not received nor do I expect to receive sick pay, under a wage continuation
plan established through conipany policy or a labor agreement, for a period after the
actual date I last worked.
48
1 have received sick pay, under a wage continuation plan established through
company policy or a labor agreement, for a period after the actual date I last worked.
49
1 expect to receive sick pay, under a wage continuation plan established through
company policy or a labor agreement, for a period after the actual date I last worked.
Earnings I~iformation
50 In
, (prior year) your total earnings were $999,999.99.
51
In
, (prior year) your nonrailroad earnings were less than $999,999.99.
52
In
, (prior year) you earned more than $9999 in each month.
53
, (prior year) you earned less than $9999 in the following months:
In
January February March April May June July August September October
November December
, (current year) you expect your total earnings will be $999,999.99.
54
In
55
, (current year) you expect your total nonrailroad earnings will be less than
In
$999,999.99.
56
In
57
, (current year) you expect to earn more than $9999 in each month.
In
, (current year) you expect to earn less than $9999 i ~tlie
i following niontlis:
January February March April May June July August September October
November December
58
In
, (next year) you expect your total earnings will be $999,999.99.
59
In
, (next year) your total nonrailroad earnings will be less than $999,999.00.
Criminal Offense Information
60
Within the past 12 months I have not been imprisoned or been given a sentence of
RRB Form AA-lcert (xx-xx)
32948 64790 22000 06051 32704
Page 5
United States of America
Railroad Retirement Board
Form Approved
OMB 3220-0002
confinement due to a conviction for a criminal offense.
61
Within the past 12 months I have been irr~prisonedor been given a sentence of
confinement due to a convictioli for a criminal offense.
Beginning Dates and Filing Dates
62
You requested your annuity begin on the earliest date permitted by law, even if you
will receive a reduced annuity.
63
You have requested your annuity begin on the earliest date permitted by law, as long
as it does ~ i oresult
t
i ~ai reduced annuity.
64
You have selected mmlddlyyyy for the beginning date of your annuity.
65
This application will protect your filing date for Social Security benefits.
66
You do not want this application to protect your filing date for Social Security
benefits.
Medicare
67
You are enrolled in the Medicare Medical lnsurance Plan (Part B).
68
You wish to enroll in the Medicare Medical lnsurance Plan (Part B).
69
You do not wish to enroll in the Medicare Medical lnsurance Plan (Part B) at this
time.
70
My annuity will begin before I am age 63 and I am totally disabled for work.
71
You are claiming a special enrollment period based on coverage by an employer
grol-lp health plan.
72
You are claiming premium surcharge relief based on coverage by an employer group
health plan.
RRB Form AA-1 cert (xx-xx)
32948 64790 22000 06051 32704
Page 6
United States of America
Railroad Retirement Board
Form Approved
OMB 3220-0002
-
Application for (Applicatio~iType) Certification
RR Claim Number
Name
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 or withhold information, 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 tlie RRB irr~niediatelyif there are any errors i ~tlie
i Surr~mary
I received, and have made and initialed ally corrections on the Summary being returned
to the RRB.
Printed if application is for Employee Annuity and employee is FRA or older
I have received and reviewed the booklets RB-1 Age and Service Employee Annuityand
RB-9 Employee and Spouse Annuities - Events that Must be Reported. I understand that
I am responsible for reporting events that would affect my annuity. Failure to report any of
the events that may affect my annuity may result in a penalty deduction'from my annuity,
criminal and/or civil prosecution.
Printed if application is for Employee Annuity and employee is under FRA
I have received and reviewed the booklets RB-1 Age and Service Employee Annuity, RB9 Employee and Spouse Annuities - Events that Must be Reported and form G-77a How
Work Affects Your Railroad Retirement Benefits. I understand that I am responsible for
reporting events that would affect my annuity. Failure to report any of the events that may
affect my annuity may result in a penalty deduction from my annuity, criminal and/or civil
prosecution.
Printed if application is for Disabled Employee Annuity
I have received and reviewed tlie booklets RB-1 Age and Service Employee Annuity, RBI d Employee Disability Benefits and RB-9 Employee and Spouse Annuities - Events that
Must be Reported. I understand that I am responsible for reporting events that would
affect my annuity. Failure to report any of the events that may affect my annuity may
result in a penalty deduction from my annuity, criminal and/or civil prosecution.
I agree to immediately notify the RRB, if
I go to work for a railroad or railroad labor organization, or return to work in any
capacity in the railroad industry;
RRB Form AA-I cert (xx-xx)
32948 64790 22000 06051 32704
Page 7
United States of America
Railroad Retirement Board
Form Approved
OMB 3220-0002
I begin to receive a pension based on earnings that are not covered by the Social
Security Administration or the Railroad Retirement Board;
I file for social security benefits on any person's account;
Benefits I receive directly from the Social Security Administration are adjusted for a
reason other than normal cost-of-living increases;
I am filing in advance and my last date of employment changes;
I return to work for (print last nonrailroad emplover);
I earn over the annual earnings exempt amount;
My expected earnings amount changes;
I perform work, including self-employment, for a family owned controlled or
managed business, including a business operated, managed or owned by me, a
fan-lily nier~ber,friend or close associate whether for pay or not and without regard
to how the business is organized (e.g., sole proprietorship, partnership, corporation,
LLC, etc.);
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;
I receive anything of value in lieu of salary or wages for any work that I perform;
I begin to receive workers compensation or public disability benefits;
I receive a settlement with credit for railroad service as "pay-for-time-lost" for
months after (print date railroad emplovment ended);
I receive lump-sum payment or begin to receive a monthly pension from my railroad
employer;
My address changes;
My bank account changes;
I am confined to a jail, prison, penal institution, or correctional institution due to a
conviction for a criminal offense;
My spouse who is receiving a benefit dies or our marriage ends in divorce or
annulment;
A qualifying child marries or leaves my custody or residence.
Signature (First Name, Middle Initial, Last Name)
Date (MonthlDayNear)
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 of Witness
Signature of Witness
Address (Street, City, State and ZIP Code)
Address (Street, City, State and ZIP Code)
RRB Form AA-lcert (xx-xx)
32948 64790 22000 06051 32704
Page 8
Form Approved
OMB 3220-0002
United States of America
Railroad Retirement Board
Daytime Telephone Number
RRB Form AA-lcert (xx-xx)
Daytime Telephone Number
32948 64790 22000 06051 32704
Page 9
| File Type | application/pdf |
| File Modified | 2010-03-24 |
| File Created | 2010-03-24 |