AA-4 (proposed) Self-Employment and Substantial Service Questionnaire

FORM APPROVED
OMB No 3220-0138

UNITEDSTATESOF AMERICA
RAILROADRETIREMENT
BOARD

Do NOTWRITEIN THIS SPACE
APPROVED
BY

SELF-EMPLOYMENT
AND

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Paperwork Reduction[Ad3/Privacy 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.
The 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 OMB 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 completion time, to the chief of Information
[Rewuroes] Management, Railroad Retirement Board, 844
North Rush Street, Chicago, Illinois 6061 1-2092.

Always complete Sections 2 and 3 and Sections 5 through 7 of this form. Complete Section 4, as applicable, as explained in the
instructions at the beginning of that section.
Type or print legibly in ink. 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 June 6,2007, as:

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If vou are com~letinathis auestionnaire on behalf of someone else. vou must answer each auestion as it amlies to the a ~ ~ l i c a n t .

Check the information entered by the Railroad Retirement Board (RRB) for ltems 1 through 3 for accuracy.
b If the information is correct, g o t o ltem 4.
b If the information is not correct, cross out the incorrect information and enter the correct information above it.
b If the information is missing, fill it in.

-

If you are also completing Form AA-I, Application for Employee Annuity, or Form AA-3, Application for
SpouselDivorced Spouse Annuity, go to ltem 7. Otherwise complete Items 5 and 6.
5 MAILINGADDRESS

CITY AND STATE
ZIP CODE

Form AA-4 (xx-xx) (DESTROY
PRIOREDITIONS)

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74the name of your business and the legal form of that business
{i.e., corporation, sole proprietorship, partnership, consultant, etc.).

If

F

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A D e s c r i b e the tppedsservice you perform and the skill level required.the name(s)
and address(es) of the persons or organizations for whom you perform this service. (As used in this questionnaire, "person" means individual, organization, or company.)

A
or more of the person(s) listed in item

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name(s) of that employe

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service you p e r f o r m z h e same as the service you performed as an employee?l)b

lob a & x p l a i n how your current service differs from the service you performed as an employee.

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Form AA-4 (%#

Page 2

Attachment 2
Enter an "X" in the appropriate box to indicate your form of business.
Corporate
Sole Proprietorship
Partnership
Consultant
Other (Describe) :
Enter an "X" in the appropriate box to indicate your job title.
Project Managermeam Leader
OwnerIPartner
Sales Person
Officer of Corporation
Consultant/lndependent Contractor
Minister
Other (Describe):

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r service (i.e., home, your own office, premises of the

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12 Enter an "X" in the appropriate box.
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Yes

0

No

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13 Enter the date you began performing

your service.

of your service.

A
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-

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u,
you determine your own working hour
lsbwdetermines
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'horYLS7

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Page 3

Form AA-4

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supervised,

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Y~d-b+JtrHbb &bkb w 17
scribe the extent to which you are

who -us

b-erson

supervises

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&mplet&ms
18 through 20 (anc@m 21 if yourRRB annuity began before this y e a r ) d ~ are
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claiming that you did not perform substantial service in self-emplo ment for one or more months in that
is the only section on this
year. Otherwise, leave these items blank and

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

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e amount of your earnings from the business that would continue based solely on the capital you have
invested in it without any service performed by you.

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Page 4

Enter a monthly breakdown of
of time you spent
last year. If
regular bu~sinesshours 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

FEE

JAN

Enter a monthly breakdown of
of time you spent
loyment this 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.

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1
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JUNE

JULY

AUG

JAN

FEE

MAR

APR

MAY

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1

JUNE

1
I

JULY

I

AUG

1

SEPT

OCT

NOV

DEC

JAN

FEE

MAR

AP R

1
I

I

1

APR

MAY

SEPT

Enter a monthly breakdown of
your net earnings after deduction of allowable business
under each month of
mployment performed

MAR

JAN

NOV

DEC

FEB

MAR

AP R

I

1

I

MAY

I

I
JULY

JUNE

I

I

SEPT

I

OCT

OCT

AUG

I

NOV

DEC

-the
person(s) for whom you perform the
reportewi.e., as wages,

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Page 5

Form AA-4 @@

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,,&,IOU pay sel

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the income received for the services you prov

b e d o not pay sefiemployrne

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medical insurance) of the person

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with which you perform your services7scribe the verbal agreement-

~a copy
t
of the con

28 Enter an "X" in the appropriate box:
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uoup.

personal financial loss i n m businesz

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Form AA-4

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Page 6

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Yes
No

Attachment 3
28.

a.

Is there a written contract in accordance with which you perform your services?
Yes Read Note then go to Item 29
No - Go to Item 28b

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Note: If answered "Yes,"you must submit a copy of the contract.

b.

Describe the verbal agreement.

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2

u receive money for your servcies"f
dule (i.e., weekly, bi-weekly, monthly!
- .,el
- br ~
scribe 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.
'1

30

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Page 7

Form AA-4

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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.
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SIGNKI'LIRE
(First IVame, Middle
Initial, Last Name)

DATE

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

REFER ANY QUESTIONS TO:
Form AA-4

Page 8

Attachment 4