Form RL-94F (06-03) RL-94F (06-03) Survivor Questionnaire

In reply refer to RRB Claim Number

1

Social Security Number
Name of Deceased Railroad Employee
Name of Deceased Annuitant

Please fill in the items on the following pages so that we can determine whether benefits are
payable under the Railroad Retirement Act due to the death of the person named above. If you do
not know the answer to an item, write "Unknown" in that item. Return the completed form to the
Railroad Retirement Board (RRB) using the enclosed envelope.
If the person was receiving an annuity under the Railroad Retirement Act, the annuity is not
payable for the month in which the annuitant died. Annuity checks are dated the first of the month
and cover payment for the previous month. If you receive a check(s) for any month(s) for which
the person should not be paid, you should return it to the:
Department of the Treasury
Philadelphia Financial Center
P.O. Box 51319
Philadelphia, PA 19115-6319

or

RRB field office
at address shown above

If the person was enrolled in Direct Deposit, notify the financial institution to return all payments
that are received after the date of death.
'This is not an application for benefits. If benefits are payable, the eligible person(s) will be
required to file an application.
Special Instructions
If there is an "X" in this box, complete only Sections 4 and 6.
Sincerely,

Enclosure

United States of America
Railroad Retirement Board

FORMAPPROVED
OMB NO. 3220-0032

Survivor Questionnaire
Section 7 0 ) of the Railroad Retirement Act (RRA) of 1974 authorizes the U.S. Railroad Retirement Board to gather
information and records needed to assure pro er administration of the RRA. The information obtained from this
questionnaire will be used for determining w ether benefits are a able under the RRA. Althou h you are not required
to furnish this information which is necessary to determine eligi i ity for benefits, if you fail to o so, nonpayment of
benefits may result.
We estimate this form takes an average of 10 minutes per response to complete, including the time for 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 dis lays a valid OMB number. If you wish, send comments regarding the accuracy
of our estimate or any other aspects o this form, including suggestions for reducin completion time, to Chief of
Information Resources Management, Railroad Retirement Board, 844 North Rush treet, Chicago, Illinois 60611-2092.

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Print all answers in ink or use a typewriter. If you need more space than is provided to answer a question, continue in
Section 5. If you do not know the answer to a question, print "unknown" in the space provided for the answer.
Some items on this questionnaire 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 slup to another item number. Follow the instructions that tell you to "Go to" another item.
These are designed to save you time and help you move through the questionnaire quickly. If no "Go to" instructions
are given, answer the next item in order. Do not skip any items unless directed to do so.

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ldentifying Information

Check the information entered by the Railroad Retirement Board (RRB) for Items 1 through 6 for accuracy.
b If the information is correct, go to Section 2.
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.
1

Deceased Employee's Name

2

Deceased Employee's Social Security Number

3

Deceased Employee's Railroad Retirement Claim Number

4

Place of Death (City and State)

7

8

6 Date of Death

5 Date of Birth

Information About Employee's Work Services and Family
If the employee was ever in active military service enter
the dates of service, otherwise go to Item 8.
b

Month

From
Day

Year

Month

To
Day

Year

Furnish the following information regarding the employee's employment after stopping work in the railroad
industry. (Include any part-time work. If the employee worked for himherself, write "self-employed" in the first
column.)
Name and Address of Employer

Began
Month Year

Ended
Month Year

United States of America
Railroad Retirement Board

9

FORMAPPROVED
OMB NO. 3220-0032

Was the employee survived by a widow(er) or a remarried
(Check one) b
widow(er)?
a Widow(er)'s Name, Address, and Telephone Number

Yes - Complete a-e, below
No - Go to Item 10

Name
Address
Telephone Number (Include area code)
b

Widow(er)'s Date of Birth

c Widow(er)'s Date of Marriage to Employee

Is the widow(er) disabled for all regular employment? (Check one) b
Were the employee and widow(er) living together at
the same address at the time of the employee's death? (Check one) b
10 Was the employee survived by a divorced spouse to
whom he or she was married at least 10 years or who has (Check one) b
children of the employee in his or her care?
a Divorced Spouse's Name, Address, and Telephone Number
d
e

Yes

No

Yes

No

Yes - Complete a-d, below
No -Go toItem 11

Name
Address
Telephone Number (Include area code)
b

Divorced Spouse's Date of Birth

c Divorced Spouse's Date of Marriage to Employee

d

Is the divorced spouse disabled for all regular
Yes
(Check one) b
employment?
NO
11 Was the employee survived by:
a unmarried children under age 18? (Includes a
Yes
natural child, stepchild, adopted child, or
(Check one) b
NO
dependent grandchild.)
b unmarried children who have been continuously
Yes
(Check one) b
disabled since before age 22?
NO
c unmarried children age 18- 19 who are full-time
Yes
(Check one) b
students at an elementary or high school?
No
d a parent age 60 or over who was dependent on
Yes
(Check one) b
the employee for at least one-half support?
NO
12 Enter all survivors for whom "Yes" is indicated in Item 11. If more space is needed, continue in Section 5.
Name and Address

Month

Date of Blrth
Year
Day

Relationship
To Employee

FORMAPPROVED
OMB NO. 3220-0032

United States of America
Railroad Retirement Board

Information About Employee's Burial Expenses and Estate
Complete Items 13 through 17 only if the employee was not survived by a widow(er) who was living with the employee
at the time o f death.
13 Name and Address of the funeral director who buried the employee.

14

Name, Address, and Telephone Number of the person who paid or will pay the burial expenses.

15

Have all of the burial expenses been paid?

16

a. Did, or will, the payer of the burial expenses use
hisher own funds (including a joint account with the
deceased)?
b. Did, or will, the payer of the burial expenses use the
funds of the employee's estate?
c. Did, or will, the payer of the burial expenses use the
funds of others? If "Yes," explain below.

17

Yes
No
Yes
NO
Yes
No
Yes
No

(Checkone) b
(Check one) b
(Check one) b
(Checkone) b

Has a court appointed administrator or executor been
Yes - Complete Item 17a
appointed, or expected to be appointed? Answer "No" if (Check one) b
No - Go to Section 4
someone has been named in the employee's will only.
a. Court Appointed Administrator's Name, Address, Telephone Number and Date of Appointment
Name
Address
Telephone Number (Include area code)
Date of Appointment

- m A
Information About Employee's Survivors
18 Give the information requested below about the employee's living relatives on1 if there are no survivors listed in

r

Item 12 or, if there is an "X" in the special instructions box on the first page o this form, give the information
requested below about the em loyee s Children. If no child survives, then the Grandchildren. If no andchild
survives, then the Parents. I none of the preceding relatives survive, then the Brothers and Sisters
date of
birth needed.)
Relationship
Date of Birth
Name, Address, and Telephone Number
to Employee
Year
Month
Day

P

60

United States of America
Railroad Retirement Board

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19

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FORM
APPROVED
OMB NO.3220-0032

Remarks

o

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

e

~

Certification

I understand that iving fraudulent, false or incomplete information to the Railroad Retirement Board to cause
payment of bene its is a crime punishable by Federal law. I certify that the information that I have provided is
true, correct and complete to the best of my knowledge.
Signature of Person Furnishing Information
Relationship to Employee

?

Number and Street Address

Telephone Number (Home)

City, County, State and ZIP Code

Month
Date b

Telephone Number (Work)
Day

Year

Form RL-94F (06-03)