AA-11a (09-03) Designation or Change of Beneficiary for Employees with

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

FORM APPROVED
OMB NO. 3220-0031

FOR RRB USE ONLY

DESIGNATION OR CHANGE OF BENEFICIARY
FOR EMPLOYEES WITH SERVICE
PRIOR TO JANUARY 1,1975
FOR RESIDUAL LUMP SUM

Acceptable
Not Acceptable (Explain on a separate sheet)
Approved By
Field Office Name & No.
Filing Date

(See Instructions for completing and
mailing this form on the next page)

Important.-- This form is authorized under Sections 6(c) and 7 of the Railroad Retirement Act. Read the information in Items 1, 2, 3,
and 4 below AND on the next page before filing this form.
PRINT OR TYPE THE FOLLOWING IDENTIFYING INFORMATION
Complete Mailing Address (NumberlStreetlCity/StatelZipCode) Name of Railroad Employee
RRB Claim Number (If Any)

Social Security Number
I

Date of Birth (MonthlDayNear) b

1. I hereby designate the person(s) named below to receive any residual lump sum payable under Section 6(c)(2) of the Railroad
Retirement Act. I direct that if any named person predeceases me, that person's share shall be distributed equally to the
surviving beneficiary(ies) shown. NOTE: If you name more than one person, the residual lump sum will be distributed in equal
shares unless you indicate the percentage to be paid to each.
a. First name, middle initial
I b.
I c.
I d.
(maiden name if married),
Share to be Paid
Relationship
Complete Mailing Address
and last name of each
Each Beneficiary
beneficiary

2. If no person named in Item 1 above survives me, I designate the beneficiary(ies) named below. I direct that if any named person
below predeceases me, that person's share shall be distributed equally to the surviving beneficiary(ies) shown. NOTE If you
name more than one person, the residual lump sum will be distributed in equal shares unless you indicate the percentage to be
paid to each.
a. First name, middle initial
I b.
I c.
I d.
(maiden name if married),
Share to be Paid
Complete Mailing Address
Relationship
and last name of each
Each Beneficiary
beneficiary

3. By this designation I revoke all designations I have previously made, if any. I understand that this designation will remain in effect
unless changed or revoked by me.
SIGNATURE OF RAILROAD EMPLOYEE

DATE SIGNED (MonthlDayNear)

4. WITNESSES (NOTE: A person listed above as a beneficiary CANNOT be a witness.)
We, the undersigned, certify that this instrument was subscribed in our presence and in the presence of each other on the date
shown above, and that the railroad employee declared it to be hislher free act and deed.
Complete Mailing Address (NumberlStreetlCitylStatelZip Code)
a. Signature of Witness
b. Signature of Witness
I

Code)
Complete Mailing Address (NumberlStreet~CityIStatelZip
I

I

Form AA-I l a (09-03) Destroy Prior Editions

IMPORTANT NOTICES
This form pertains to payment of a residual lump sum (RLS) to your survivors. An RLS is a special payment under the Railroad
Retirement Act to insure that you and your survivors receive at least as much in railroad retirement benefits as you paid in railroad
retirement taxes before January 1, 1975 (plus an allowance for interest). Most employees do receive benefits exceeding their
taxes. Beneficiaries must be specifically named. You may designate your estate, but designations such as "son," "heirs," or
"executor" are not acceptable.

WHO SHOULD FILE
1.

An employee who may haves residual lump sum and wishes to designate beneficiaries must meet the following conditions:
P You began to work for a railroad or other employer covered by the Act before 1975, and
P you wish to designate your own beneficiary (see Railroad RetirementAct Order of Precedence below), and
P you have not received a railroad retirement annuity or have received one for less than two years.

2.

An employee who wishes to change beneficiaries.

3. An employee who filed a designation of beneficiary before June 22, 1948, on Form AA-11, which is no longer valid. If you still
wish to have a designation on record, you must file a new form.

Railroad Retirement Act Order of Precedence
If a residual lump sum becomes payable and you have not desiclnated a beneficiarv to receive the amount, or if no desiclnated
beneficiarv survives vou, the residual lump sum will be paid as follows.
a.
b.
c.
d.
e.
f.

To your widow(er) if living with you at the time of your death. If no eligible widow(er) survives, to
your child or children in equal shares. If no child survives, to
your grandchild or grandchildren in equal shares. If no grandchild survives, to
your parent or parents In equal shares. If no parent survives, to
your brothers and sisters in equal shares. If no brother or sister survives, to
your estate.

INSTRUCTIONS FOR COMPLETING THIS FORM
1.

Print all answers in ink or use a typewriter.

2.

Sign and date Item 3 in ink. A signature by mark (X) is acceptable.

3. Two witnesses must certify the signature of the designator in ltems 4a and 4b. One or both witnesses may be Railroad
Retirement Board employees.
4.

If you show percentages in ltems I d or 2d, be certain that the total shares equal 100 percent.

5.

Any individual, partnership, association, joint stock company, or corporation may be designated as beneficiary. Miscellaneous
provisions, such as "payment of just debts," "payment on the monthly installment plan," etc., should not be incorporated into this
form and will not be recognized.

6.

The form should be free of erasures or alterations to avoid a possible contest after your death.

7.

The form must be returned in person or by mail to the nearest office of the Railroad Retirement Board on or before the date of
your death. A copy will be sent to you for your records after it has been reviewed.

8.

An inaccurately completed form will cause us to return the form to you for correction.

PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICES
The Ra~lroadRetirement Board is authorized to collect the information on this form under Section 7(b)(6) of the Railroad Retirement
Act. The information asked for on this form is needed to designate a beneficiary or beneficiaries whom you want to receive any
residual lump sum (RLS) payment that is payable in the event of your death. You are not obligated to complete this form, however,
if you do not, any residual lump sum that becomes payable will be paid as specified above in the order of precedence. A complete
listing of the persons, organization, and agencies to which the information you give us may be released is available at any office of
the Railroad Retirement Board.
We estimate this form takes an average of 10 minutes per response to complete, 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 comments regarding the
accuracy of our estimate or any other aspect of this form, including suggestions for reducing completion time, to Chief of
Information Resources Management, Railroad Retirement Board, 844 North Rush Street, Chicago, IL 60611-2092.

Form AA-I Ia (09-03) Destroy Prior Editions