AA-21CERT Application Summary and Certification

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0031

APPLICATION SUMMARY and CERTIFICATION
Employee's Name ,
RR Claim No., .

.

1

The followirrg information was either supplied by or verified by you in support of your
application for Lump Sum Death Payment under the Railroad Retirenient Act. After you
have reviewed the information, make any changes on the summary, initial the change
and sign the certification on the last page. Return the certification and all pages of the
summary to the RRB.
Employee lnformation
Social Security Number
Date of Birth
Date of Death

)FXI-..XX-XXX~
10-17-1971
04-06-2002

Military Service
The employee was not in active n-lilitary service after September 7, 1939
Recent Employment
The employee has not worked in the last three years.
The employee's net earnings from self-employment were less than $400 in each of the
last three years.
Railroad Employment
The employee had a current connection with the railroad ilidustry.
Employee's Family
The employee was not survived by a widow(er) who is eligible for monthly benefits.
The employee was not survived by a surviving divorced spouse who is eligible for
monthly benefits.
The employee was not survived by children or grandchildren who are eligible for monthly
benefits.
The employee was not survived by a parent who is eligible for monthly benefits.
Applicant lnformation
RRB Form AA-2lcert (02-00)

32948 64791 21999 06051 32704

Page 1

Form Approved
OMB 3220-0031

United States of America
Railroad Retirement Board

Name and Address
Social Security Nurrlber
Daytime Telephone Number
Type of Application Filed

Lump Sum Death Payment

You applied for this benefit based on being responsible for the payment of the
employee's burial expenses.
You have requested that any payment due you be sent to the following bank account:
Citibank Financial Services
Bank Name
Routing Number
%)ON
Account Number
X%X'X
Account Type
Checking

,

Burial Expense Information
Total funeral home expenses:

$9,000.00

Amount paid with your own money:

$4,000.00

Amount paid with the employee's money:

$1,000.00

Amount remaining unpaid:

$4,000.00

Reimbursement
You have not and will not receive money or property to reimburse you for the burial
expenses you paid.

-

Application for Lump Sum Death Payment Certification
Employee's RR Claim Number
Employee's Name
Employee's Social Security Number

kX x -xx-xxXX
XXX
)wx-xX-)(XW

Applicant's Name
Applicant's Social Security Number

~xx-xx-XXX.X

RRB Form AA-2lcert (02-00)

XXX

32948 64791 21999 06051 32704

Page 2

Form Approved
OMB 3220-0031

United States of America
Railroad Retirement Board

I certify that the information I have given to the Railroad Retirement Board (RRB) in relation
to this application is true to the best of my knowledge. I know that if I make a false or
,fraudulent statement in order to receive benefits from the RRB, I am comn-litting a crime
which is purlishable under Federal law.

I have received and reviewed a summary of the information I provided. I understand that I
have an obligation to advise the RRB immediately if there are any errors in the summary I
received, and have made and initialed any corrections on the Summary being returned to the
RRB.
I agree not to request or accept reimbursement from another party for that part of the burial
expenses for which I arrl reimbursed by the lump-sum death payment.

I have received and reviewed the booklet RB-21 LUMP-SUM DEATH PAYMENT,
RESIDUAL LUMP-SUM, AND ANNUITIES UNPAID AT DEATH]

Signature (First Name, Middle Initial, Last Name)

Date (MonthIDayNear)

If this certification is signed by mark ("Xu),two witnesses who know the person signing must sign below,
giving their full addresses and daytime telephone numbers.

Signature of Witness

Signature of Witness

Address (Street, City, State and ZIP Code)

Address (Street, City, State and ZIP Code)

u
Daytime Telephone Number

(1
Daytime Telephone Number

RRB Form AA-21cert (02-00)

32948 64791 21999 06051 32704

Page 3