Form SSA-671 Railroad Retirement Questionnaire

SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB No. 0960-0078

TOE 420

DATE

RAILROAD EMPLOYMENT QUESTIONNAIRE

SOCIAL SECURITY NUMBER

NAME OF PERSON ON WHOSE RECORD SOCIAL SECURITY BENEFITS ARE CLAIMED

A. To be completed whenever the deceased worked the railroad industry on or after January 1937.
1. HOW MANY MONTHS DID THE DECEASED
WORK IN THE RAILROAD INDUSTRY AFTER
1936?

2.

HOW MANY MONTHS DID THE DECEASED
WORK IN THE RAILROAD INDUSTRY BEFORE
1937? (IF NONE, ENTER "NONE")

3.

DID THE DECEASED WORK IN THE RAILROAD
INDUSTRY DURING THE LAST 18 MONTHS?
YES

NO

(if "yes" also complete C below.)
4. IF THE DECEASED'S RAILROAD SERVICE TOTALS AT LEAST 120 MONTHS, OR 60 MONTHS
AFTER1995, DID THE DECEASED EVER FILED A CLAIM FOR A DISABILITY OR RETIREMENT ANNUITY

WITH THE RAILROAD RETIREMENT BOARD?

YES

R.R.B. CLAIM NUMBER

NO

IF "yes", enter the R.R.B. Claim Number
5. HAS ANY SURVIVOR OF THE DECEASED EVER RECEIVED A LUMP-SUM 6.
OR RESIDUAL PAYMENT OR A SURVIVOR'S MONTHLY ANNUITY FROM
THE RAILROAD RETIREMENT BOARD?
YES

IF THE DECEASED EVER FILED AN APPLICATION FOR SOCIAL SECURITY
BENEFITS DID THE DECEASED WORK IN THE RAILROAD INDUSTRY AT ANY
TIME AFTER FILING FOR SOCIAL SECURITY BENEFITS?

NO

YES

NO

(If "yes," also complete C below.)

(If "yes," also complete D below.)

B. To be completed whenever a claim for Social Security benefits is filed and the claimant or claimant's spouse worked in the railroad
industry on or after January 1, 1937.
1. NAME OF PERSON HAVING RAILROAD EMPLOYMENT
2. HOW MANY MONTHS DID THE PERSON NAMED 3.
IN B(1) ABOVE WORK IN THE RAILROAD
INDUSTRY AFTER 1936?

SOCIAL SECURITY NUMBER

HOW MANY MONTHS DID THE PERSON NAMED
IN B(1) ABOVE WORK IN THE RAILROAD
INDUSTRY BEFORE 1937? (if none, enter
"none.")

4.

DID THE PERSON NAMED IN B(1) ABOVE WORK IN
THE RAILROAD INDUSTRY DURING THE LAST 18
MONTHS?
YES

NO

(If "yes," also complete C below.)
5. IF THE RAILROAD SERVICE TOTALS AT LEAST 120 MONTHS, OR 60 MONTHS AFTER1995, DID THE
R.R.B. CLAIM NUMBER

PERSON NAMED ABOVE EVER FILE A CLAIM FOR A DISABILITY OR RETIREMENT ANNUITY WITH THE

RAILROAD RETIREMENT BOARD?

YES

NO

IF "yes", enter the R.R.B. Claim Number
6. DID THE PERSON NAMED IN B(1) ABOVE RECEIVE ANY RAILROAD SICKNESS BENEFITS OR ANY

RAILROAD UNEMPLOYMENT BENEFITS DURING THE LAST 18 MONTHS?

YES

NO

(If "yes," also complete C below.)

C. To be completed if item A(3) or A(6) or B(4) or B(6) is checked "yes."
NAME OF RAILROAD EMPLOYER

WORK LOCATION

FROM

TO

DEPARTMENT AND OCCUPATION

D. To be completed when the claimant for Social Security benefits has received a lump-sum from the R.R.B. or has received or is
receiving a monthly R.R.B. annuity based on another individual's railroad employment.
1. NAME OF SOCIAL SECURITY CLAIMANT--R.R.B. ANNUITANT

2. R.R.B. CLAIM NUMBER

3. NAME AND SOCIAL SECURITY NUMBER OF RAILROAD EMPLOYEE ON WHOSE RECORD THE R.R.B. CLAIM WAS FILED
NAME

SOCIAL SECURITY NUMBER

4. RELATIONSHIP OF S.S. CLAIMANT TO RAILROAD EMPLOYEE (Wife, widow, 5.
parent, child, etc.)

TYPE OF R.R B. BENEFIT (Monthly, lump-sum or residual)

6. HAS THE RAILROAD RETIREMENT BOARD NOTIFIED THE ABOVE SOCIAL SECURITY CLAIMANT R.R.B. ANNUITANT THAT THE AMOUNT OF THE R.R.B. ANNUITY MAY BE AFFECTED BY
ENTITLEMENT TO SOCIAL SECURITY BENEFITS?

Form SSA-671 (03-2005) EF (03-2005) Destroy Prior Editions

YES

NO

Check √ here and use reverse for
additional remarks.

PRIVACY ACT/PAPERWORK ACT NOTICE: Your response to this request is voluntary; however,
failure to provide all or any of the information requested may, affect the final decision on your
claim. The information requested on this form is authorized by sections 205(i) and 205(o) of the
Social Security Act. The information you furnish will enable the Social Security Administration to
insure proper credit is given for railroad industry employment and to facilitate any required
coordination with the Railroad Retirement Board.

Paperwork Reduction Act Statement - This information collection meets the requirements of 44
U.S.C. § 3507, as amended by Section 2 of the Paperwork Reduction Act of 1995. You do not
need to answer these questions unless we display a valid Office of Management and Budget
control number. We estimate that it will take about 5 minutes to read the instructions, gather the
facts, and answer the questions. SEND THE COMPLETED FORM TO YOUR LOCAL SOCIAL
SECURITY OFFICE. The office is listed under U. S. Government agencies in your telephone
directory or you may call Social Security at 1-800-772-1213. You may send comments on our
time estimate above to: SSA, 1338 Annex Building, Baltimore, MD 21235-6401. Send only
comments relating to our time estimate to this address, not the completed form.
REMARKS