Form AA-4 (07-01) AA-4 (07-01) Self-Employment and Substantial Service Questionnaire

SELF-EMPLOYMENT AND

SUBSTANTIAL SERVICE

QUESTIONNAIRE

Papework ReductionIPrivacy Act Notice
The Railroad Retirement Board (RRB) is authorized to collect
the following requested information under Section 7(b)(6) of
the Railroad Retirement Act (RRA). This information is needed
to determine whether your self-employment will affect your railroad retirement benefits under the RRA. You are not required
to provide the information requested by this form. However,
your failure to provide us with the requested information may
result in our being unable to pay you any benefits.
~h~ information you provide may be disclosed for purposes
of verification to the employer(s) named in item 8. A complete
listing of the persons, organizations and agencies to which
the information you give us may be released is available at
any office of the RRB.

We estimate this form takes between 40 and 70 minutes per
response, including the time for reviewing the instructions,
getting the needed data, and reviewing the completed form.
Federal agencies may not conduct or sponsor, and respondents are not required to respond to a collection of information unless it displays a valid OlVlB number. If you wish, send
any comments regarding the accuracy of our estimate or any
other aspects of this form including suggestions for improving the c o m ~ l e t i o n time. to the Chief of Information
Management, Railroad Retirement Board, 844 North Rush
Street, Chicago, Illinois 60611-2092.

Always complete Sections 1-3 and Sections 5-7 of this form. Complete Section 4, as applicable, as explained in the instructions at the beginning of that section. Print all answers in ink or use a typewriter. If you are completing this form on behalf of
someone else, you must answer each question as it applies to that person. If you need more space than is provided to answer
a question, use Section 6 for this purpose. If you do not know the answer to a question, print "unknown" in the space provided
for the answer. When entering dates, always use numbers. Also, be sure there is one number in each box. For example, you
would enter January 1, 2000, as:

Look over the information entered by the RRB for items 1, 2 and 3 to be sure it is correct. If it is correct,
go to item 4. If the information is not correct, line it out and enter ,the correct information.

F

r

fY

2

If you are also completing Form AA-I, Application for Employee Annuity or Form AA-3, Application for

SpouselDivorced Spouse Annuity, go to item 7. Otherwise complete items 5 and 6.

CITY AND STATE

ZIP CODE
A

-

4 YOUR NAME

6

DAYTIME

---+

-

-

- -

- --

TELEPHONE NUMBER (INCLUDE AREA CODE) -+
Form AA-4 (07-01) (DEs- ROY PRIOR EDITIONS)

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7 Print the name of your business and the legal form of that business
(i.e., corporation, sole proprietorship, partnerstlip, consultant, etc.).

8 List your title or position. Describe the type of service you perform and the skill level required. List the name(s)

and address(es) of the persons or organizations for whom you perform this service. (As used in this questionnaire, "person rr means individual, organization, or company.)

8
LY
P.

A

9 State whether or not you are a former employee of one or more of the person(s) listed in item 8. If so, list the
name(s) of that employer(s). Otherwise, go to item 11.

- .

10 State whether or not the service you perform is the same as the service you performed as an employee. If it is
not, explain how your current service differs from the service you performed as an employee.

$

d
0
LL

A

Form AA-4 (07-01)

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11 Describe where you perform your service (i.e., home, your own office, premises of the
"person" shown in item 8).

LU

I

12 Enter an "X" in the appropriate box:

I advertise my services ,to the public.

9

13 Enter the date you began performing

your service.
-

-

-

-

a

Yes

O

No

-

-

14 State whether or not your services are scheduled to end on a certain date, and if so, what that date is. If
they are not scheduled to end on a certain date, describe the agreement you have concerning the length
of your service.

I 5 State whether or not you determine your own working hours. If you do not determine your working hours,
state who determines them.

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Form AA-4 (07-01)

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16 State whether or not you are supervised. If you are supervised, describe the extent to which you are supervised
and provide .the title of the person who supervises you.

Complete items 18 through 20 (and item 21 if your RRB annuity began before this year) only if you are
claiming that you did not perform substantial service in self-employment for one or more months in that
year. Otherwise, leave these items blank and go to Section 5. (Note that this is the only section on this
form that may be left blank, as applicable.)
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V

18 Print the approximate value of the business and the percent of the business that you own.

w

19 Print the amou~itof your earl-lings from the business that w o ~ ~continue
ld
based solely on the capital you have
invested in it without any service performed by you.

-z
&

A

Form AA-4 (07-01)

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Enter a monthly breakdown of
the amount of time you spent
in self-employment this year. If
regular business hours varied
during certain mo~ithsof the
year, state the reason for the
variance(s) (i.e., vacation, sickness, etc.) in Section 6.

Enter a monthly breakdown of
the amount of time you spent
in self-employment last year. If
regular business hours varied
during certain months of the
year, state the reason for the
variance(s) (i.e., vacation, sickness, etc.) in Section 6.

Enter a monthly breakdown of
your net earnings after deduction of allowable business
expenses under each month of
self-employment performed
this year.

FEB

MAR

APR

MAY

JUNE

JULY

AUG

SEPT

OCT

NOV

DEC

JAN

FEB

MAR

APR

MAY

JUNE

JULY

AUG

SEPT

OCT

NOV

DEC

JAN

FEB

MAR

APR

JUNE

I

JULY

I

AUG

I
-

Enter a monthly breakdown of
your net earr~i~igs
after deduction of allowable business
expenses under each month of
self-employment performed
last year.

JAN

SEPT

OCT

JAN

FEB

MAR

APR

MAY

JUNE

JULY

AUG

SEPT

OCT

NOV

DEC

-

NOV

-

DEC

-

State whether or not the payments you receive are reported to the Internal Revenue Service (IRS) by the
person(s) for whom you perform the services. If the payments are reported to the IRS, state how they are
reported (i.e., as wages, non-employee compensation, etc.).

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Form AA-4 (07-01)

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:

25 State whether or not you pay self-employment tax based on the income received for the services you provide.
If you do not pay self-employment taxes, state the reason.

I-

!-

V

26 State whether or not you participate in a fringe benefit program (i.e., group medical insurance) of the person
named in item 8. If you do participate in a fringe benefit program, describe the benefits.

V

27 State whether or not there is a written contract in accordance with which you perform your services. If so,
submit a copy of the contract. If there is no written contract, describe the verbal agreement under which you
perform services.

A

V
V3
~3

0

-I

28 Enter an "X" in the appropriate box:
I risk personal financial loss in my business.
Form AA-4 (07-01)

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0
O

yes
No

29 State whether or not you receive money for your services. If you do receive money for yo[-lr services,
describe your pay schedule (i.e., weekly, bi-weekly, monthly). If you do not receive money for your services,
describe the nature of payment or reimbursement you receive for your services. List any expenses you have
that are not reimbursed.

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.

A

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Form AA-4 (07-01)

31 1 certify that all the information I have provided in completing this form is true to the best of my knowledge. I
know that if I have made a false or fraudulent statement on this form or if my refusal to provide this information
reflects a fraudulent intent to obtain benefits not authorized by law, I am committing a crime which is punishable
under Federal law by fine or imprisonment or both.

SIGNATURE
(First Name, Middle
Initial, Last Name)

-

DATE
I

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32 Witnesses are required only if this questionnaire is signed by mark ("X"). If signed by mark ("X"), two
witnesses who know the person signing must sign below, giving their full addresses.

1. Signature of Witness

Address (Number and Street, City, State, and ZIP Code)

2. Signature of Witness

Address (Number and Street, City, State, and ZIP Code)

MAIL THIS QUESTIONNAIRE TO THE ADDRESS SHOWN BELOW. MOST RAILROAD RETIREMENT BOARD
OFFICES ARE OPEN TO THE PUBLIC FROM 9:00 AM THROUGH 3:30 PM MONDAY THROUGH FRIDAY.

REFER ANY QUES1-IONS TO:
Form AA-4 (07-01)

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