Application for Spouse/Divorced Spouse Annuity

UNITED STATES OFAMERICA
RAILROAD RETIREMENT BOARD

FORM APPROVED
OMB NO. 3220-0042

DO NOT WRITE IN THIS SPACE
OFFICIALLY FILED
MONTH
DAY

APPLICATION FOR
SPOUSEIDIVORCED
SPOUSE ANNUITY

OFFICE NUMBER

YEAR

APPROVED

I
DATE CODED

APPLICATION NUMBER

CODED BY

Before you complete this application, be sure to read the booklet RB-30, Spouse/Divorced Spouse Annuity, which explains information
you will need to answer many of the questions in this application. Also be sure to read the important notices at the end of the booklet
RB-30.
Type or print legibly in ink. If you need more space than is provided to answer a question, use Section 15 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, 2007, as:
Month

Day

Year

016 0 6 2 1 0 1 0 7
Some items in this application will not apply to you so you will not need to answer them. Based on your answer to a question, you may
be told to skip to another item number, or even another section. Follow the instr~~ctions
that tell you to "Go to" another item. These are
designed to save you lime and help you move through the application form quickly filling in only necessary information. If no "Go to"
instructions are given, answer the next item in order. Do not skip any items unless directed to do so.
If you are completing this application on behalf of someone else, you must answer each question as it applies to the applicant.

Identifying Information
Check the information entered by the Railroad Retirement Board (RRB) for Items 1 through 6 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 missing, fill it in.

*
*
*

1 1
1

Employee
Identification

1
I

EMPLOYEES RAILROAD RETIREMENT CLAM NUMBER

( EMPLOYEE'S SOCIAL SECURITY NUMBER

2

I3I

EMPLOYEE'S NAME

I

Appl~cant
Identification

4

APPLICANT'S NAME

5

a

-I

>

-

MAILING ADDRESS
CITY AND STATE
ZIP CODE

b

COUNTY

-

TELEPHONE NUMBER
I

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>
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Form AA-3 (03-07) Destroy Prior Editions

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1

Information About You And Your Family
Social
Security
lnforrna tion

7

Enter your social security number.

I If none, enter an "X" by "To be submitted."
9

Sex

Birthdate

Enter your nanie as it appears on your
social security card.

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

I

-+

Enter an "X" in the appropriate box:
My name appears on my social security card
exactly as it does in Item 4.

8

-

t

To be submitted

-

12 Enter your name at birth if
different from Item 4.

+

Current
Marriage

13 Enter the date of your marriage

Marital
Status

14 Enter an "X" in the appropriate box:

to the railroad employee.

w

Marital status to the railroad employee.

MALE
FEMALE
Month

Day

Year

Month

Day

Year

I

I

15 Enter an "X" in the appropriate box:

MARRIED

+

Go to Item I 5

DIVORCED

-+

Go to Item 17

No
-+ Gotoltem 19

t
--

17 Enter an "X" in the appropriate box:

Marriage
History

1

Yes +Go to ltem 18

to the railroad employee.
Marriage

1

t

16 Enter an "X" in the appropriate box:
I was married before my marriage

-

1

Yes

The railroad employee was niarried
before our marriage.

-

to ltem 10

t

Birth

- -

Go to ltem 10

NO -+ GO to ltem 9

t

+

---

-+

Yes +Go

11 Enter your date of birth.

Previous
Marriage

Go to
ltem 8

-

Yes

I was married affer my marriage

to the railroad employee.

No

>

18 If you are a spouse, enter the following information about your marriage before your marriage to the employee.

If you are a divorced spouse, enter the following information about your marriage affer your marriage to the
employee. If applicable, enter information for more than one marriage in Section 15.

I 1

Marriage Ended

Marriage Began

a
1. Date

5. Date

2. City and State

6. City and State

/

3. Former Spouse's Name

7. Reason

Death

0 Divorce

Annulment

Other - Explain in Section 15
4. Former Spouse's Social Security Number ------+

1

-

-

I Complete 18b if you do not know your former spouse's social security number.
b

1

Month

Enter your former spouse's
(1) Date of birth

t

(2) Place of birth

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(3) Father's name

+

1 1 (4) Mother's maiden name
Form AA-3 (03-07)

Day

Year

I
Page 2

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.

*

20 Enter the date of the conviction.

t

21 Enter the date of the sentence of
confinement.
-

-

22 Enter the date that confinement began.

-

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

Yes

+ Go to ltem 20

No

+ Go to Section 4

Month

Day

Year

Month

Day

Year

I

I

Month

l

l

Year

Day

Yes

*

I

+ GO to Item 24

No -+ Go to Section 4

Month

Day

Year

*

Enter the date confinenient ended.

Please read Parts I & Ill of the RB-30 booklet for information about spouse and divorced spouse annuities and reductions for
early retirement.
Type of
Annuity

17 FULL AGE ANNUITY
C]

ANNUITY BASED ON
CHILDREN

}

$
2
6::

REDUCEDAGE
ANNUITY
DIVORCED SPOUSE
WITH PREVIOUS
AGE REDUC1-ION

1

6

+

Information About Children In Your Care
Pease read Part I of the RB-30 booklet for an explanation of "chid-in-care.''
Filing
Based On
Child-lnCare

L

$o
:n
:

a Yes

26 Enter an "X" in the appropriate box:
I will accept a reduced age annuity if
I am not eligible for a full age annuity
or an annuity based on child(ren).

1

}

27 Enter an "X" in the appropriate box:
I have one or more of the railroad employee's
children in my care who are unmarried and under
age 18. (This includes natural children, adopted
children, stepchildren and dependent
grandchildren.)
I

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Page 3

C]

Yes

-t

Go to Item 28

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Form AA-3 (03-07)

Print the requested information for every child in your care who would count toward q~~alifying
you for an annuity.
in 29, and so on. If a child does not have a social security
Print the youngest child in 28, the second yo~~ngest
number, enter "TO BE SUBMITTED."
Enter an " X in the
Relationship to Employee
Child's Full Name and
appropriate box:
(Check
One)
Social Security Number
Date of Birth
The child is
disabled
28a Name

28c
Natural
28e
28d
Adopted
Year
Month
Day
Yes
Stepchild
28b
NO
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I
Grandchild

1

29a

I

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29~

Name

29b
30a Name

31b
32a Name
32b

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1

30~

30b
31a Name

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1

I

I

I

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I

1

1
I

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31c

32c
I

I

I

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Other
Natural
Adopted
Stepchild
Grandchild
Other
Natural
Adopted
Stepchild
Grandchild
Other
Natural
Adopted
Stepchild
Grandchild
Other
Natural
Adopted
Stepchild
Grandchild
Other

I

29e

29d
Month

Year

Day

Yes

El

No

3Oe

30d
Month

Year

Day

Yes

rn

NO

31e

31d
Month

Day

Year

Yes
No
32e

32d
Month

Day

Year

Yes
No

Note: To support your entitlement to a spouse annuity based on having a disabled child in your care,
either you or the employee must complete and return to the RRB Form AA-ISa, Application for
Determination of Child's Disability, for each disabled child listed in ltems 28-32.
Do not complete ltem 33 if every child in items 28-32 is living with you; go to Section 6.
----

-

33 Print the requested information for every child not living with you. Print the youngest child in (a).
Explain your parental responsibilities in Section 15.

Children
Not Living
With

Applicant

Full Name
Of Child

(

Note: ltems 34-45 are reserved.

1

I

Person With Whom Child Now Lives
Relationship
Name
To Child

Child's Address

)

Information About Your Railroad Work
Please read Part II of the RB-30 booklet for an explanation of work that you must stop.

-

Enter an "X"

in the appropriate box:
I have worked for a railroad or other employer in the
railroad industw or a railroad labor oraanization.
Last
47 Enter the name of the railroad company or railroad
Railroad
labor organization that last enlployed you.
Employmerl t .
48 Enter your payroll name and identification
number for that employer. (If you did not
work for the employer named in ltem 47 this
year or last year, leave this item blank.)

1 1

II

I

49 Enter your last job title for that employer.
(If you did not work for the employer named
in ltem 47 this year or last year, leave this
item blank.)

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Form AA-3 (03-07)

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Page 4

Yes + Go to Item 47
NO + Go to Section 7

1I 1 1
50
&;road
Employment
(Cont.)

-

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

I

I

TO

FROM

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

Month

Year

Day

Month

Year

Day

52 Enter an "X" in the appropriate box:

I relinquish my seniority rights and all other
rights to work for the employer shown in ltem 47
as of the last date entered in Item 51.
Other
Railroad
Work

Yes

O

t

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

Yes -+ Go to ltem 54

[IJ

Enter the name of that employer.

No -+ Go to ltem 60

L

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55 Enter your payroll name and Identification
number for that employer.

t

Enter your last job title for
that employer.

+

II

57 Enter your last division or department
and its location for that employer.

t

58 Enter the dates you worked for the employer
named in Item 54. (If your railroad employment
has not ended, enter the last date you will work

TO

FROM
Month

Day

59 Enter an "X" in the appropriate box:
I relinquish my seniority rights and all other
rights to work for the employer shown in
Item 54 as of the last date entered in ltem 58. -------Railroad
Ser,iority
Rights

No

60 Enter an "X" in the appropriate box:
I still have seniority rights or other rights to return
to work for a railroad employer or a railroad labor
organization not listed in ltems 47 or 54.
61 Enter the name and address of any additional
employer indicated in ltem 60 with whom you
still have rights to return to work.

Year

Month

Year

Day

yes

Yes

-+ Go

to ltem 61

No

-+ Go

to Section 7

+

ote: Your spouse annuity cannot begin until you relinquish your rights to employment
with the employer(s) named in ltems 47-61.

I

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Page 5

Form AAe3 (03-07)

1

Do not complete this section if you are filing for a divorced spouse annuity.
Nonrailroad
Work

Please read Part IV of the RB-30 booklet for information about nonrailroad work and how employment affects your
annuity.

I

Enter an "Xuin the appropriate box:
1 I worked for pay outside the railroad industry within the 6
months before the date I expect my annuity to begin. (Do
not include self-employment. Include any employment for
an incorporated business which you own or public service.)

i
1 1

I

-

Yes + Go to Note and Item 63

(g No

+ Go to Item 73

Note: If you had Last Pre-Retirement Nonrailroad Employment (LPE) after your annuity would begin,
complete Form G-IgF, Earnings Information Request, only when one of the following applies:
( I ) The annuity beginning date (ABD) is before January I of this year or
(2) the ABD is January I , or later, of this year, and you ceased working in LPE after the ABD month.

1
(

Most Recent
onr railroad
Work

I

I

63

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

I I

*

I

I

t

I

65
66

Next Most
Recent
Nonrailroad
Work

1

I

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

I

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.")

+

67

Enter an "X" in the appropriate box:
The employer named in ltem 63 is a seasonal employer.

68

Enter the name and address of your next most
recent nonrailroad employer within the 6 months
before the date you expect your annuity to begin.
Enter your last job title for that employer.

70

1 I

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

71

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.")

Year

--

Month Day

Yes

*

If none, enter "NONE" and go to ltem 73

1

t

-

Enter an "Xuin the appropriate box:
The employer named in ltem 68 is a seasonal employer.

1 am still working

yes

*

SelfIf you are employed and your business is incorporated answer Item 73 "No. Make sure Items 62-72 are also
Employment completed. If your business is not incorporated, answer ltem 73 "Yes" and go to ltem 74.
"

Enter an "X" in the appropriate box:
I was self-employed during the last

Yes +Go t o Item 74
No

6 months.

+Go t o Section 8

I

Note: If answered "Yes," complete and return Form AA-4, Self-Employment and Substantial Service
Questionnaire, to the RRB.
Form AA-3 (03-07)

Page 6

Year

I am still working

-

( 69 1

TO

SelfEmployment 74 Enter an "X" in the appropriate box:
I am still self-employed.
(Cont.)

Yes

No -+ Go to ltem 75

t

Month

75 Enter the date you were last
self-eniployed.

-+ Go to Section 8

Day

Year

t

Information About When Your Annuity Will Begin
Please read Part II of the R5-30 booltlet to find out when your annuity can begin.
Annuity
Beg inning
Date

1
/

76 Enter an "X" in the appropriate box:

Yes -+ Go to Section 9

I want niy annuity to begin on the
earliest date permitted by law.

NO

t

-+ GO to Item 77

Before answering Items 78-90! please read Part IV of the R5-30 booklet to find out how earnings can affect your annuity.
For the exempt amounts, refer to Form G-77a, How Work Affects Your Railroad Retirement Benefits.
Earnirlgs
Last
Year

I

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

C] Yes

+ Go to ltem 79

No tGo to ltem 83

+

(Year)

Enter an "XI1in the appropriate box:
My total earnings from all employment
last year were more than the annual
earnings exempt amount.

t

Enter your total earnings for last year.
(SHOW DOLLARS ONLY)

t

Yes

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.

No tGo to ltem 82

~iiq
~1
mpqm
[7)q

a

Enter an "X" in the appropriate box:
I expect my total earnings for 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.")

-

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

tGo to ltem 83

t

year in which you did not earn more than
the monthly earnings exempt amount or perform
substantial services in self-employment. ------------t

(Year)

No -+ Go to Item 83

[g Yes

82 Enter an "X" next to each month last

Earnings
This Year

tGo to ltem 80

Yes

-t

Go to ltem 84

No tGo to ltem 87

$
+

Page 7

Form AA-3 (03-07)

1

85 Enter an "X" in the appropriate box:

Earnings
This Year
(Cont.)

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.

+

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

t

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

Earniogs
Next Year
(Year)

C]

D
-+
I---

Enter an "Xuin the appropriate box:

I expect my total earnings for all employment

next year to be more than this year's annual

earnings exempt amount.

-

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

t

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.

-

Yes

-t

Go to ltem 87

No

-t

Go to ltem 86

Yes

-t

Go to ltem 88

No

-t

Go to Section 10

Yes

-t

Go to ltem 89

No

-t

Go to Section 10

Information About Social Security Benefits
Please read Part V of the RB-30 booklet to see how this application can protect your rights to social security benefits, and
to see what effect social security benefits will have upon your railroad retirement annuity.
Social
Security
Filing Date

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.)
92 Enter an "X" in the appropriate box:

Social
Security
Benefits

I I

Yes
No

-

-

I have filed, or plan to file within the next 90 days,
an application for social security benefits.

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

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

95 Enter the current total monthly amount of

your social security benefits (before
reduction for work or Medicare premiums).
I

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Form AA-3 (03-07)

C]

Yes

-t

Go to ltem 93

No

-t

Go to Section 11

Year

Month

Yes -+Go to ltem 95
------t

No

I

Page 8

-+

Go to ltem 96

$
I

Social
Security
Benetits

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 the railroad
employee or myself.

(Cont.)

a

Yes

-+ Go to ltem 97

No -+ Go to Section 11
t

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.

Information About Other Railroad Retirement Annuity
Please read Part V of the RB-30 booklet for an explanation of the reduction for other railroad retirement annuities.
Enter an "X" in the appropriate box:
I previously filed, or I am now filing for a
separate railroad retirement annuity based
on an earnings record of someone other than
the railroad employee named in ltem 3.
(Include yourself if applicable.)

Other
Railroad
Annuity

'

I

100 Print the full name of that other person.

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

11

yes

-+GO to ltem I00

NO -+ GO to Section 12

t

1

Prefix

1

If only six numbers,
enter here:

t

lnformation About Public Service Pension

I

Please read Part V of the RB-30 booklet for an explanation of the reduction for a Public Service Pension.

Public
Service
Pension

Enter an "X" in the appropriate box:
I am receiving or expect to receive a pension or I
have received or expect to receive a lump-sum
payment instead of a pension, based on my
earnings, from a agency of the Federal, state,
or local government. (Answer "No ' if your only
government pension payments are social security,
railroad retirement, veterans affairs, worker's
compensation, or black lung benefits.
Also answer "No ' if you received a lump-sum
payment that was just your contributions
to the pension fund plus interest.)

Yes -+ Go to ltem 103

1

[g

No -+ Go to Section I 3

J

t

103 Enter an "X1'in the appropriate box:
I amlwas an employee of the Federal Government. -+

/

Yes -+ Go to Note and Section 13
No

-+Go to ltem 104

Note: If answered "Yes," complete and return to the RRB, Form G-208, public
Sewice Pension Questionnaire, and verification of your pension.

\
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Page 9

Form AA-3 (03-07)

I

Public
Service
Pension
(Cont.)

Enter an "X" in the appropriate box:
On my last day of employnient,
I was employed by a state or local
government or the military service, and
social security (FICA) taxes were being
deducted from my public service earnings.

I

-+

Go to Section 13

NO

-+

Go to Note and Section 13

NOTE: If answered "No," complete and return to the RRB, Form G-208,
Public Service Pension Questionnaire, and verification of your pension.

-1
1

-

Yes

Information About Medicare

1

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

I

Please read Part VI of the RB-30 booklet for an explanation of the Medicare program.
bledicare
105 Enter an "X" in the appropriate box:
Enrollment
I have a Medicare card that shows entitlement

to Medicare medical insurance (Part B).

w

-

106 Enter your Medicare claim number.
(If this is a railroad retirement filing, enter the prefix.
If it is a social security 'filing, enter the suffix.)

107 Enter an "X" in the appropriate box:
I have filed for Part B within
the last three months.

Go to Section 14
-+

Go to ltem 108a

No -+ Goto ltem 109

w

Suffix

Prefix

-

b Enter the date you filed.

Month

Day

I

I

Year

Go to
Section 14

C

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

Yes
[ZI No

-

112 The beginning date of my EGHP coverage is:

Page 10

-+

Gotolteml12

-+

Gotoltemlll

w

111 Enter an "X" in the appropriate box:
I was previously covered by an EGHP based on my
own or my spouse's current employment.

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

I I

Yes -+ If you are under age 65 years
and 4 months, go to Section 14.
If you are older than age 65 years and 3
months, go to ltem 110.
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 14.

w

110 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.

Form AA-3 (03-07)

Suffix

Prefix

Yes

108 a 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 it
--+
is a social security filing, enter the suffix.)

II

Yes -+Go to ltem 106
,No -+ Go to ltem 107

F

Yes -,Go to ltem 113
No -+ Go to Section 14
Month

Day

Year

Month

Day

Year

I

I

1

I

1

Gotoltem114

IMedicare 113 The beginning and ending dates of my EGHP
Enrollment
coverage and the date last worked in the employment
(Cont.)

which qualified me for EGHP coverage are:

EGHP Beginning Date

+

EGHP Ending Date

**

Date Employment Stopped

I

**

1

I I

II

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

1

Yes -+ Go to ltem 115a
--------t

Yes -+ Go to ltem 115b

[Z1

--------+

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

1-

No -+ Gotoltem116

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.
w
b. I am requesting a Part B effective date of

Go to ltem 114

No -+ Go to Section 14

Month

Day

I

I

Year

1

1

Go to
Section 14

Yes
No

t

Direct Deposit

1

Please read Part VII of the RB-30 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 15, or call your financial institution for the inforn~ationyou need to complete Items 117-121, below.
If you do not have a bank account, or if you believe receiving your payments by Direct Deposit would cause YOU a
hardship, go to ltem 122.
117 Enter the name of your financial institution.

Direct
Deposit

Area Code

118 Enter the telephone number of your
financial institution.

t

119 Enter the routing transit number of your financial institution.

120 Enter your account number.

Telephone Number

A

+

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

-

Checking
Savings
Go to Section 15

122 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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Page 11

Form AA-3 (03-07)

Remarks

/ 123 1 This section is to be used for the continuation of answers to other items. Be sure to include the item number

Remarks

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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.

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Form AA-3 (03-07)

Page 12

-1

Certification
-

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

Certification

YES

NO

+ Go to Note and Item 125
+ Go to ltem 125

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-30,
Spouse/Divorced Spouse 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.

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(
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I agree to immediately notify the RRB:
IF I remarry (if I am filing for a divorced spouse annuity).

IF I go to work for a railroad or railroad labor
organization, or return to work in any
in the
railroad industry.

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IF a qualifying child marries or leaves my custody or
residence.

IF I am filing in advance of the date(s) shown in
Item(s) 51 (and 58), and there is a change in a date.

IF my address changes.
IF I am confined in a jail, prison, penal institution, or correctional facility due to a conviction for a crin-~inal
offense.

IF I receive a settlement with credit for railroad
service as "pay-for-time-lost"for months after the
date(s) shown in ltem(s) 51 (and 58).
IF I return to work for my Last Pre-Retirement
Nonrailroad Employer and there is a change in
my estimated earnings.

IF I eam more than the annual earnings exempt amount.
IF I perform work, including self-employment, for a
family owned, controlled or managed business,
including a business operated, managed or owned
by me, a family member, fiend Or
whether for pay or not, and without regard to how
the business is organized (e.g., sole prop[-ietorship,
partnership, corporation1 LLC, etc.).

IF I begin to receive benefits directly from the Social
Security Administration.
IF benefits I receive directly from SSA are adjusted for
a reason other than normal cost-of-living increases.

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.

IF I begin to receive a public service pension or there is
a change in the amount of my public service pension.
IF my marriage ends in death or divorce (if I am
filing for a spouse annuity).

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

Also, if I am covered by the earnings restriction provisions of the Railroad Retirement Act, I have received and
reviewed Form G-77a, How Work Affects Your Railroad Retirement 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.

126

SIGNATURE
(First Name, Middle Initial,
Last Name)

+

DATE

t

Month

Day

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Year

If this certification is signed by mark ("X") in ltem 125, two witnesses who know the person signing must
sign below, giving their full addresses and daytime telephone numbers.
a. Signature of Witness

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b. Signature of Witness

Address (Number and Street)

Area Code

Address (Number and Street)

Telephone Number
Page I 3

Area Code

Telephone Number
Form AA-3 (03-07)

How To Return Your Application

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 shown on
page 15 of this application. 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

*

ADDI1-IONAL 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.

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Form AA-3 (03-07)

Page 14