Application for Employee Annuity

Jnited States of America
?ailroad Retirement Board

Form Approved
OMB No. 3220-0002
Do Not Write In This S ~ a c e

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1

OFFICIALLY FILED
MONTH

(

DAY

I

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YEAR

I

I LASTER

APPLICATION FOR

1

OFFICE NUMBER

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NEXT-TO -LAST ER

APPROVED

EMPLOYEE ANNUITY

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

..,..

. ,...

.... ...,..,.,...... .. .

.

...............,...

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

.

DATE CODED
YEAR

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General Instructions
Before you complete this application, be sure to read the booklet RB-1, 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 on
the inside back cover of the booklet RB-1.
Print all answers in ink or use a typewriter. 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.
When entering dates, always use numbers. Also, be sure there is one number in each box. For example, you would enter
June 6, 2001 as:
MONTH

DAY

YEAR

0 , 6 0 6 2 0 1 01
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.

1

If you are completing this application on behalf of someone else, you must answer each question as it applies to the applicant.

I

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.
t If the information is not correct, cross out the incorrect information and enter the correct information above it.
If the information is missing, fill it in.

*
*

-

RAILROAD RETIREMENT CLAIM NUMBER
2

1

SOCIAL SECURITY NUMBER

--

---

-I

EMPLOYEE'SNAME

3

I

5

ZIP CODE

-.

---

--

t

--t

DAYI-IME TELEPHONE NUMBER

-

--

-

- ---

-.

>
Form AA-I (05-04) Destroy Prior Editions

Information About You and Your Family
Sex

Birthday
Marital
Status

6

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

t

7

>
Enter your name at birth if different from ltem 3. -

8

Enter your date of birth.

t

9

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

>

1 /

a Male
a Female
Month

Year

Day
I

I

10

Enter your spouse's full name before your marriage.

11

Enter your spouse's date of birth.

a Never Married
a Married or Separated
a Other

--I

Month

+

I

12

I 1
13

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14

I I

Enter the date of your marriage.

t

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

t

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.)

>

1I

Go to Item 10
Go to Item 14

Year

Day
1

Month

Go to Item 16

1

Year

Day

0 Yes

+ Go to ltem 15

a N o

+Gotoltem16

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

(i) MARRIAGE BEGAN
DATE

CITY & STATE

(iii) MARRIAGE ENDED

(ii) NAME OF FORMER
SPOUSE

DATE

REASON

a
a
a

a

CITY & STATE

DEATH
DIVORCE
ANNULMENT
OTHER - Explain in
Section 21

Month

(iv) Enter your former spouse's date of birth. t

Year
I

I
i
If unknown, enter unknown and complete ltem 15b.

(v) Enter the Social Security Number of former spouse
t
shown in Section 1 Sa(ii).
b

Day

-

I

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

Mother's maiden name

----+

Please read Chapter 2 of the R B - I booklet for an explanation of family members who could qualify you for the
Special Guaranty Computation.

1 16 1 Enter an "X" in the appropriate box:
I have children who are unmarried and meet any of the
F
following conditions:
(1) Under age 18.
(2) Age 18 through 19 and attending elementary or
secondary school full-time.
(3) Age 18 or older with a continuing disability that began
before age 22 and prevents any kind of employment.

I

1
+ Go to Note and ltem 17
No + Gotoltem 18

Yes

a

Note: If you have a child that meets the disability requirements, also complete Form AA-19a,
Application for Determination o f Child's Disa bilify.

I I
17

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

(05-04) Page 2

*

U

a

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 employment.

Do not complete ltem 18 if you have never married; go to ltem 19.

I

Garnishment
or
Property
Settlement

Enter an "Xuin 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.)

*

b. Which situation applies?

1 1
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Criminal
Offense

19 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.

21

Enter the date of the sentence of confinement.

I1
*

-

+ G o to ltem 18b

No

-+ G o to ltem 1 9

a

Child Support or Alimony

a
a

Yes + Go to ltem 20
No

Month

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

*

+ Go to Section 4
Day

Year

Day

Year

I
I

Month

I

Month

Enter the date the confinement began.

22

Yes

a Property Settlement

*

20 Enter the date of the conviction.

a
a

1

a

Year

Day

I
Yes + Go to ltem 24
NO

+ Go to Section 4

lnformation About Type of Annuity
Please read Chapter 1 of the RB-1 booklet for information about age and service annuities. Also read the RB-ld booklet if you
are applying for a disability ann~~ity.
Type of
Annuity

1 25 1

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

*

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.
I

I

-

0
0
0

FULL AGE ANNUITY
FULL 60130 AGE ANNUITY
DISABII-ITY ANNUITY

0

REDUCED AGE ANNUITY- LESS
THAN 30 YRS' SERVICE

a
a

ltem 26

}

Go to
Section 5

1

Yes

I

lnformation About Military Service

I
I

Please read Chapter 3 of the RB-1 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.

a
a

Yes

+ Go to
+

I
I

Note and Item 28

Go to Section

Note: If answered "Yes, " you must submit proof of your military service, such as your discharge certificate

or separation papers, as explained in the RB-I booklet.
Enter an " X in the appropriate box:
I had voluntary military service during the period June 15,
1948, through December 15, 1950.

a
a

-a

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.

+ Go to Item 29
No + Go to Item 30

Yes

Yes

Form AA-I (05-04) Page 3

Iblilitary
Service
Monthly

Enter an " X in the appropriate box:
I have filed, or plan to file, a daim for monthly benefits with another
federal agency based on military service performed before
January 1,1957. (Answer "No" if the other federal agency is the
Department of Veterans Affairs, the Social Security Administration,
t
or the Railroad Retirement Board.)

Benefits

Enter the name of the other federal agency.

1

Go to ltem 31
Go to Section 6

-*
Year

Day

Enter the claim number of the monthly benefit you have

33

I

No

Enter the date you filed a claim with the agency named in Item 31 Month
and go to ltem 33. If you have not already filed a daim with that
agency, enter the date you plan to file and go to Section 6. --+

32

1

a Yes -+
a -+

I already filed for.

>

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Information About Your Railroad Work
Please read Chapter 4 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.
Railroad
Work Before

I

1937

Enter an "X" in the appropriate box:
I have less than 360 months of railroad work
after 1936.

+

-

Enter an "X" in the appropriate box:
I worked in the railroad industry before 1937.

a Yes -+
a -+
No

Go to ltem 35
Go to ltem 36

m Yes -+ Go to Note and ltem 36
No

-+ Go to ltem 36

Note: To obtain credit for your railroad senlice before 1937, complete and return to the RRB, Form AA-15,
Employee's Statement of Service Performed Before January 1,1937, to Employers Under the Railroad
Retirement Act
Last Railroad 36
Employment

Enter the name of the railroad con-lpany or railroad
labor organiza,tionthat last employed you.

Enter your payroll name and identification nurnber for
that employer.

37

>

Enter your last job title for that employer. >
-

38

Enter your last division or department and its location.

+

I TO

FROM
Month Day

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.)

Year

Month Day

Year

+

-

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

Enter an "X" in the appropriate box:
I worked for another employer in the railroad industry
or a railroad labor organization this year or last year. ---+

42

Railroad
Employment

43

I

>

Enter your payroll name and identifcation nurr~berfor
that employer.

+

Enter your last job title for that employer.

45
I

Enter the name of that employer.

I

Form AA-1 (05-04) Page 4

m Yes -+ Go to Item 43
m No Go to Item 49
-+

P

I

I

Other
Railroad
Employment
(Cont.)

Print your last division or department and its
location for that employer.
47

1
49

FROM
Month Day

Enter the dates you worked for that employer.
r
employment has not ended,
(If y o l ~railroad
enter the last date you will work for that
employer in the "TO" date.)

48

Railroad
Seniority
Rights

w
Year

TO
Month Day

Year

*

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

~~~~h

Year

D~~

*I

Enter an "X" in the appropriate box:
I still have seniority or other rights to work for a
railroad employer or railroad labor organization
not listed in Item 36 or Item 43.

*

Print the name of any employer indicated
in ltem 49 with whom you still have rights
to return to work.

t

I

a

Yes

m No

+ Go to Item 50
+ Go to Section 7

lnformation About Pay For Time Lost

1

Please read Chapter 6 of the RB-7 booklet to find out what payments can be creditable as pay for time lost.

I

Pay For
Time Lost

51

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

-

u Yes
m No

+ Go to Note and Item 52

+ Go to Section 8

I

Note: If Item 51 is "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 2I .
Enter the dates for which
these payments were made or
will be made.

1

I

Year

TO
Month1 Day

I

Year

+

lnformation About Railroad Sick Pay
Please read Chapter 5 of the RB-7 booklet to find out when sick payments can be creditable to Tier I.
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.)

a

I

FROM
Month1 Day

i

I

1bI

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

C)Yes + Go to ltem 54a

u No

+ Go to Section 9

*

I

Enter the dates for which these payments were made or will be made for
up to six months after your actual day
last worked.

1 TO

1 FROM
Month Day

+

Year

Month Day

Year

I

Form AA-1 (05-04) Page 5

x f o r r n a t i o n About Your Nonrailroad Work
Please read Chapter 8 of the RB-I booklet for information about "Last Pre-Retirement Non-Railroad Employment,
self-employment, and other earnings." This chapter explains how this employment affects your annuity. Also read
Chapter 9 of the booklet.
Nonrailroad
Work

Enter an "X" in the appropriate box:
I worked for pay outside the railroad industry
either during the last 12 months I worked in the
railroad industry or after I left the railroad industry.
(Include any employment for an incorporated
business which you own, or elected public service. Do not include self-employment. If you are
a Canadian citizen or permanent resident, include
employment in Canada for the U.S. railroad
employer January 1, 1983, or later.)

CI Yes + Go to Note and ltem 56
+ Go to ltem 66

No

>

[ ~ o t e : If you expect your annuity to begin before January 1 of this year and you had last pre-retirement nonrailroad employment after your annuity would begin, complete Form G-19L, Annual
Earnings Questionnaire: Last Pre-Retirement (Non-Railroad) Employment, Self-Employment,
and Other Earnings.
Most Recent

Nonrailroad
Work

I I
57

1 1
58

59

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

>

Enter your current or most recent job title
for ,that employer.

>

Enter your average monthly salary for that employer.
(SHOW DOLLARS ONLY)
FROM
Month Day

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.")

>

Enter an "X" in the appropriate box:
'The employer named in ltem 56 is a
Federal Government agency that is listed in
Chapter 9 of the RB-I booklet.
Next Most
Recent

1 1
62

Enter your last job title for that employer.

Year

I

1

Year

I

[7 I am still working

CI Yes
CI

>

If none, enter "NONE and go to ltem 66

Enter the name and address of your next most
recent nonrailroad employer during your last 12
months in the railroad industry or after you left
the railroad industry.

Nonrailroad
Work

I

I

I

TO
Month Day

P

Enter your average monthly salary for that employer.
(SHOW DOLLARS ONLY)

64

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.")
Enter an "X" in the appropriate box:
The employer named in ltem 61 is a
Federal Government agency that is listed in
Chapter 9 of the RB-I booklet.

Form AA-1 (05-04) Page 6

FROM
Month1 Day

I

Year

I

I

* CI I am still working
CI
>

cl

Yes

TO
Month1 Day
I

1

I

Year

SelfEmployment

If you are employed and your business i s incorporated, answer ltem 66 "No." Make sure ltems 55-65 are also
completed. If your business i s not incorporated, answer ltem 66 "Yes" and go to ltem 67.

I I

1

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

m Yes + Go to ltem 67
No

+ Go to Section 10

Note: If answered "Yes," complete and return to the RRB, Form AA-4, Self-Employment and
Substantial Service Questionnaire.
Enter an " X in the appropriate box:
I am still self-employed.

67

-1
+

m Yes + Go to Section 10
m No + G o t o l t e m 6 8

MONTH

Enter the date you were last self-employed.
I

I

I

1 1
D*/

I

YEAR

I

1
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Deemed Current Connection
Please read Chapter 9 of the RB-1 booklet for an explanation of a deemed current connection.
69

Deemed
Current
Connection

I I

I

70

Enter an "X" in the appropriate box:
I have at least 25 years of railroad service
and I have indicated nonrailroad employment
in ltems 55-68 that could break my current
connection.

Yes -+ Go to ltem 70

Enter an "X" in the appropriate box:
I was separated from my last railroad
employer involuntal-ilyand through no fault
of niy own on or after October 1, 1975.

>

I

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.

1 I
72

II
I I
I

m No

-+ Go to Section 11

D Yes

-+ Go to ltem 72

m No

-+ Go to Item 71

I

t

m Yes -+ Go to ltem 72
m No -+ Go to Section 11

>

1

Enter an "X" in the appropriate box:

I declined an offer to work in the railroad

industry in tlie sanie "class or craft" as my
last railroad job.

Yes -+ Go to Section 11
No

+ Go to Note and Section 11

I

If you answered either ltem 70 or ltem 71 "Yes" and ltem 72 "No," submit the required proofs a
soon as possible. This will preserve your rights under the deemed current connection provisions. The
k q u i r e d proofs are explained in the RB-I booklet.

I

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Information About When Your Annuity Will Begin
Please read Chapter 10 of the RB-1 booklet to find out what determines your annuity beginning date.
-

Annuity
Beginning
Date

73

74

Enter an "X" in the appropriate box:
I want my annuity to begin on the
earliest date permitted by law.
Enter the date you want your annuity
to begin.

-

p~

-

Yes -+ Go to Section 12
w

m No
Month

>

-+Go to ltem 74
Year

Day
I
I

I

l

l

Form AA-1 (05-04) Page 7

Information About Your Earnings
Please read Chapter 11 of the RB-1 booklet to find out how earnings can affect an age and service annuity. Also
refer to Form G-77a, How Work Affects Your Railroad Retirement Benefits, for the exempt amounts to use
when answering ltems 75-87. If you have attained full retirement age or will attain full retirement age this year or
next year, please read the RB-1 booklet before answeriog ltems 75-87.
If you are applying for a disability annuity but are eligible for and would accept a reduced age annuity if the disability
annuity is denied, answer ltems 75-87 which apply to the reduced age annuity. Otherwise, g o t o Section 13.
Earnings
Last Year

m Yes
* m No

Enter an "X" in the appropriate box:
I expect my annuity to begin before
January 1 of tl- is year.

75

+ Go to ltem 76

+ Go to ltem 80

(Year)

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

76

0 Yes + Go to ltem 77

m No

*

I I
77

79

I I

Enter your total earnings for last year.
-

-

-

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)

82

83

I I

Earrings
Next Year

m No

+ Go to ltem 79

m Yes
m No

+ Go to ltem 81
+ Go to ltem 84

m Yes
m No

+ Go to ltem 84

D Yes

+ Go to ltem 85

m No
m Yes
m No

+ Go to Section 13

+ Go to ltem 83

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.

(Year)

+ Go to ltem 80

*

Enter an "Xuin 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. -+

I I

I

I

*

Enter the total amount you expect to earn this year.

81

Yes

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.

1 80 1 Enter an "X" in the appropriate box:
I

Go to ltem 80

(SHOW DOLLARS ONLY)

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.

78

+

*

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

Form AA-1 (05-04) Page 8

I

+ Go to ltem 86
+ Go to Section 13
J

Earnings
Next Year
(Cont.)

-

86

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

87

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.

(Year)

$

r----pqrpq~---pq
*

lnformation About Social Security Benefits
Please read Chapter 12 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.
Social
Security
F~lingDate

88

89

90

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.)

a
a

Yes

*

-

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.

a
a

Yes -+ Go to ltem 90
No

Year

Month

Enter the date you became, or will become, eligible
for these social security benefits.

-+ Go to Section 14

*
I

91

92

93

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

+

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

*

a
a

Yes

-+

Go to ltem 92

No

-+

Go to Item 93

$

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.

-

94

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

95

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

a
a

Yes

-+

Go to Item 94

Section l4

w

lnformation About Noncovered Service Pension
Please read Chapter 13 of the RB-I booklet for information concerning noncovered service pensions. Complete Items
96 and 97 only if your date of birth is January 2, 1924, or later. Otherwise, go to Section 15.
tioncovered
Service
Pension

96

97

Enter an "X" 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.

*
*

a
a
a
a

Yes

-+

Go to Item 97

No

-+

Go to Section 15

Yes

-+Go to Note and Section 15

No

-+

Go to Section 15

Note: Complete Form 6-209, Employee Non-Covered Service Pension Questionnaire.
Form AA-1 (05-04) Page 9

lnformation About Other Railroad Retirement Annuity
Please read Chapter 14 of the RB-I booklet for an explanation of the effect of your employee annuity on any other
railroad retirement annuity.
Other

98

Railroad
Annuity

1 99 1 Enter the full name of that other person.

I

-

Enter an "X" in the appropriate box:
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.

01 Yes + Go to Item 99
01 No + Go to Section 16

1

P

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

Prefix

If only six numbers, enter here

1 1

w

1

I

I

1

lnformation About Supplemental Annuity
Please read Chapter 15 of the RB-I booklet for an explanation of what is required to be eligible for a supplemental
annuity.
Supplemental 101 Enter an "X" in the appropriate box:
I am now, or will be, eligible for a supplemental annuity
Eligibility
from the Railroad Retirement Board (before reduction
>
for a company pension).

01 Yes + Go to Item 102
01 No + Go to Section 17

102 Enter an "X" in the appropriate box:
I am receiving, or expect to receive, a monthly
pension or lump-sum pension payment from one
or more former railroad en-~ployers.

01 Yes + Go to Item 103
01 No + Go to Section 17

Annuity

>

-

103 Enter the name of the last railroad employer
with whom you still hold pension rights.

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

01 Salaried
01 Non-Agreement
01 Agreement
01 Other

+

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

Month

Year

Day
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-

106 Enter the name of the second to last railroad employer
with whom you still hold pension rights. (If this
employer is now part of the employer in ltem 103,
leave this item blank and go to ltem 109.)
107 Enter an "X" in the box which most accurately
applies to the job or position which qualified
you for this pension.

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

01 Salaried
01 Non-Agreement
01 Agreement
01 Other

*

Month

>

Day
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109 Enter an "X" in the appropi-iate box:
The pension described in Item 103 or Item
106 is based on a collective bargaining
(union) agreement.

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Form AA-1 (05-04) Page 10

Year
I

'

01 Yes
01

>
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-1

Information About Medicare
Complete this section only if you are 64 years and 5 months of age or older.

Please read Chapter 16 of the RB-I booklet for an explanation of the Medicare program.
-

-

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

+
111 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).
112 Enter an "X" in the appropriate box:
I have filed for Part B within the last
+
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

01 Yes
01 No
Month

Go to ltem 113

-+

Go to ltem 114

Day

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.

01 Yes + Go to ltem 117
01 No + Gotoltem116

>

-

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:

Year

I

Go to Section 18

01

115 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.

01 Yes + Go to ltem 118
01 No + Go to Section 18

\

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

+

-

The beginning and ending
dates of my EGHP cover- EGHP Beginning Date +
age and the date last
worked in the employment EGHP Ending Date
which qualified me for
Date Employment Stopped +
EGHP coverage are:

1

II

I

-+

/

a

119

+ Go to ltem 112

I

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

I

+ Go to ltem 111

Go to Section 18

II
1 1

01 Yes
01 No

1

1

1 Go to Item 119 I

Enter an "X" in the appropriate box:
I wish to enroll in a special enrollment period. >

01 Yes
01 No

+ Go to ltem 120

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.

01 Yes
01 No

+ Go to ltem 120b

+

Month

b. I am requesting a Part B effective date of

+ Go to ltem 121

+ Go to Section 18
Year

Day

Section 18

I

-

121 Enter an "X" in the appropriate box:
I am requesting premium surcharge relief
for the months of EGHP coverage.

-

01 Yes

01
Form AA-1 (05-04) Page 11

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 afier 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, lnformation About the Taxation of
Railroad Retirement Annuities, Part 6, Section 6A.
Disability
Medicare

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

>

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

I I

I I

I

a
a
a
a

No

+ Go to ltem 123
+ Go to Section 19

Yes

+ Go to Note and Section 19

No

+ Go to Section 19

Yes

( ~ o t e :Complete and return Form AA-Id, ~ ~ ~ l i c a tfor
i b Determination
n
of Employee's
~isability,to apply for Medicare based on disability.

,,(

\

I

lnformation About You If You Are Disabled
Answer Items 124-126 ONLY if you are applying for a disability annuity. Otherwise, go to Section 20. If you are applying
for a disability annuity, also complete and return Form AA-Id, Application for Determination of Employee's Disability.
You are asked about your children to determine if you are entitled to a special annuity cornputation.
Please read Chapter 17 of the RB-I booklet for an explanation of worker's compensation benefits and public disability
benefits.

1 1

Child Living
JWithYOU

124 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.

rrkerls
1 1

125 Enter an "X" in the appropriate box:
Since my disability began, I have
received, or expect to receive,
worker's compensation benefits.

+

a
a

>

Yes

+ Go to Note and ltem 126

No

+ Go to ltem 126

I

ote: Proof of the amount(s) and effective date(s) of your worker's compensation benefit is required.

I Public
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.)

Disability
Benefits

a
a

Yes

+ Go to Note and Section 20

No

+ Go to Section 20

>

( Note: Proof of the amount(s) and effective date(s) of your public disability benefit is required. )
I

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F o r m AA-1 (05-04) Page 12

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-1
(

Direct Deposit
Please read Chapter 20 of the RB-I booklet for an explanation of Direct Deposit.
Benefits are generally paid by Direct Deposit to your bank, savings and loan, credit union, or other financial institution.
To provide the information we need to correctly deposit your payments, attach a voided personal check and go to
Section 21, or call your financial institution for ,the information you need to complete Items 127-1 31. If you do not
have a bank account, or receiving your payments by Direct Deposit would cause you a hardship go to Item 132.

Direct
Deposit

127 Enter the name of your financial institution.

-*
Area Code

128 Enter the telephone number of your
financial institution.

Telephone Number

*

- aa

1129 Enter the routing transit number of your financial institution.
I

130 Enter your account number.

I

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

Checking
Savings

I

I I

II

I

Go to Section 21

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

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Remarks

I

I

Remarks

I

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.

Form AA-1 (05-04) Page 13

m
E
:edification

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

CI YES -+ Go to Note and Item 135
CI NO -+ Go to Item 135

*

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.

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-7, Age
and Service Employee Annuity 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 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 I begin to receive a pension based on earnings that are not covered by the Social Security Administration;
IF I begin to receive benefits directly from the Social Security Administration;
IF I am disabled and begin to receive worker's compensation or public disability benefits;
IF I am entitled to a supplemental annuity and begin to receive a pension or lump-sum payment 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 any employer in the railroad industry;
IF I am filing in advance of the date(s) shown in Item(s) 40 (and 47), and there is a change in a date;
IF I return to work for the nonrailroad ernployer(s) named in Items 56 and 61 or, if there is a change in my
earnings from these employers;
IF benefits I receive directly from the Social Security Administration are adjusted for a reason other than normal
cost-of-living increases;
IF my address changes; or
IF I am confined in a jail, prison, penal institution, or correctional facility due to a conviction for a criminal offense.
Also, if I am covered by the earnings restriction provisions of the Railroad Retirement Act, I agree to immediately notify the RRB if I earn more than the annual earnings exempt amount. Failure to report my earnings on
a timely basis may result in a penalty deduction from my annuity, and/or criminal prosecution.
SIGNATURE
(First Name, Middle Initial,
Last Name)

*

DATE

**

If this certification is signed by mark ("X") in ltem 135, two witnesses who know the person signing must
sign below, giving their full addresses and daytime telephone numbers.
a. Signature of Witness

/
I

~ d d r e s s(Number and Street)
City, State. ZIP Code
Area Code

Daytime Telephone Nun-~ber

-

--

-

-

.

Telephone Number

>

--

I

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b. Signature of Witness

1 ~ d d r e s s(Number and Street)

1

City, State, ZIP Code
Area Code

Daytime Telephone Number

- -

-

--

-

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,rm AA-I I

Page 14

Telephone Number

->
,

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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 a// 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
ofice serving your location. 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:

*

needed proofs

*

the application form itself

*

additional forms you were asked to corr~plete

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.

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Form AA-I (05-04) Page 15