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pdfUNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD
FORMAPPROVED
O.M.B. No. 3220-0030
DO NOT WRITE IN THIS SPACE
OFFICIALLY FILED
Application
for
Widow(er)'s Annuity
OFFICE NUMBER
APPROVED
1
I
DATE CODED
MONTH
APPLICATION NUMBER
I
DAY
I
YEAR
I
I
CODED BY
General Instructions
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Before you complete this application, be sure to read Part I of booklet RB-17, Survivor Annuities, which explains information you will need
to answer many of the questions in this application.
If filing for a widow(er)'s disability also complete Form AA-17b.
Please read "Important Notices" on page 14 of this application.
Print all answers in ink or use a typewriter. If you need more space than is provided to answer a question, use Section 9 for this purpose. If
you do not know the answer to a question, print "unknown" in the space provided for the answer.
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When enteringdates, always use numbers. Also, be sure there is one number in each box. For example, you would enter February 12,
2001, as:
MONTH
012
DAY
1
YEAR
112 2101011
Some items in this application 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 skip to another item number, or even another section. Follow the instructions that tell you to "Go to" another item. These are
designed to save you time and help you move through the application form quickly, filling in only necessary information. 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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If you are completing this application on behalf of someone else, you must answer each question as it applies to the applicant.
Check the information entered by the Railroad Retirement Board (RRB) for Items 1 through 6 for accuracy.
rc If the information is correct, go to Section 3.
If the information is not correct, cross out the incorrect information and enter the correct information above it.
a- If the information is missing, fill it in.
*
Employee 1
ldentification
2
1 1
3
1 1
Applicant
4
Identification
1 1
EMPLOYEE'S NAME
-
EMPLOYEE'S SOCIAL SECURITY NUMBER
-
P
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EMPLOYEE'S RAILROAD RETIREMENT CLAIM NUMBER
APPLICANT'S NAME
C
ZIP CODE
d
COUNTY
.--
-
6 DAYTIME TELEPHONE NUMBER
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Form AA-17 (10-07) Destroy Prior Editions
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1 If a railroad retirement survivor benefit was previously received by someone, go to Section 4; otherwise go to ltem 7.
_
7 Enter the employee's date of birth.
Birth Date
Month
Year
Day
C
If the employee was age 62 or older when he or she died, go to ltem 9.
a Yes
a
Disability
8 Enter an " X in the appropriate box:
The employee was unable to work at the time of death because of an
illness or accident which occurred at least five months before death. -'
Military
Please read the section "Credit for Employee's Military Sewice" in Part V of the RB-17 booklet to find out
how active military service is determined.
Service
Enter an "X" in the appropriate box:
The employee was in active milily sewice after September 7,1939.
-
a Yes + Go to Note and ltem 10
No
+ Go to ltem I 2
Note: If answered "Yes," you will have to submit proof of the employee's military
sewice. If you cannot submit proof show, in ltem 83, the branch of the sewice
and the beginning and ending dates for each period of sewice.
Enter an "Xin the appropriate box:
The employee had voluntary military service during the
period June 15,1948, through December 15,1950.
Enter an " X in the appropriate box:
The employee had nonrailroad earnings after leaving the military service and before returning to the railroad.
7
Yes
No
+ Go to ltem 11
+ Go to Item 12
a Yes
a
>
No
Regardless of whether the employee was retired at death, show the name and address of each railroad or
nonrailroad employer for whom the employee performed any part-time or full-time work during the last 3
years he or she worked. Print the name and address of the most recent employer in 12a, the second in 12b,
and so on. Enter the date each job began and ended.
Employment
Name and Address of Employer
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a Name
Address
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I
Address
Ended
Month
Year
Month
Year
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City, State, ZIP Code
Name
1
Began
Began
Month
I
Year
1
1
Ended
Month
1
Year
City, State, ZIP Code
Name
Address
City, State, ZIP Code
Enter an "Xin the appropriate box:
The employee was self-employed
during any of the last three calendar years.
SelfEmployment
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1
1
Month
I
1
1
1
Year
1
1
Month
1
Year
1
1
1
l
1
Began
Ended
Yes
No
+ Go to ltem 14
+ Go to ltem 16
Enter an "X" in the appropriate box:
The employee's net earnings from self-employment were
more than $400 in any of the last three calendar years.
Yes
No
+ Go to ltem 15
+ Go to ltem 16
Enter an " X in the appropriate box(es):
Show the year or years in which the employee's net
earnings from self-employment were more than $400.
This year
>
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Form AA-17 (10-07)
-
Page 2
Last year
U
Year before last
Railroad
Employment
Answer Items 16 and 17 only if the employee was alive on October 1, 1981, and he or she had at least
25 years of railroad service; otherwise go to Item 18.
If the employee was alive on October 1, 1981, and had at least 25 years of railroad service, read the section
"Requirements the Employee Must Have MeV in Part I of the RB-17 booklet to find out what special conditions
may apply.
\
Note: You may be requested to submit proof to verifL the statements
made in ltems 16 and 17.
16 Enter an " X in the appropriate box:
The employee "involuntarily and without fault":
II II
stopped working for his or her last railroad
employer on or after October 1, 1975, or
was on furlough, leave of absence status, or
absent because of injury on October 1, 1975,
and was never called back to work for that
employer.
- aa
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17 Enter an " X in the appropriate box:
The employee declined an offer from a railroad employer to return
to a job in the same "class or craft" as his or her last railroad job. +
Yes + Go to Itern 17
No + Go to Itern 18
a yes
a
No
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Employee's 18 Enter the requested information for each of the employee's marriages. Print the most recent marriage in 18a,
Marriages
the second most recent in 18b, and so on.
Answer if Marriage Ended for Reason
Other than Employee's Death
Name of Employee's
Wife or Husband
(if wife, include
maiden name)
a
b
City and State
Married
(country if other
than United States)
Date
Married
Month Day
Year
Month Day
Year
How Marriage
Ended
(check one)
Date Marriage
Ended
Death Month
Day
City and State
Marriage Ended
(country if other
than United States
Year
O Spouse's Death
O Divorce
O Annulment
Death
O Spouse's Death
~
~ D~~
~ year
t
h
a Divorce
Annulment
C
Children
Month Day
Employee's Death Month Day
Year
Year
O Spouse's Death
0 D'lvorce
O Annulment
Please read the section "Definition O f A Child's Annuity" in Part I1 of the RB-17 booklet to find out what categories
of children may be eligible for a railroad retirement annuity.
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19 Enter an "X" in the appropriate box:
There are children who may be eligible
for a annuity.
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20 Enter the number of children who may be eligible for an annuity.
Page 3
a Yes + Go t o Itern 20
a No + Go to Itern 21
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Form AA-17 (10-0i
Enter an "X" in the appropriate box:
The employee was survived by a parent.
a Yes +Go to Item 22
a No +Go to Section 4
a Yes + Go to ltem 23
a No + Go to Section 4
*
22 Enter an "X" in the appropriate box:
The parent was dependent on the employee
for one-half of his or her support.
23 Enter the requested information for each dependent parent of the employee.
Name of Parent
Date of Birth
a
Address and Telephone Number
Year Address
Day
--
Month
Telephone Number (include area code)
(
Month
)
Day Year Address
Telephone Number (include area code)
Information About The Applicant
Birth Date
Security
Number
Marriages
24 Enter your date of birth.
Month
Day
Year
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d
25 Enter your social security number.
(If none, enter "To be submitted.")
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w
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26 Enter an "X" in the appropriate box:
I am now, or was previously, married to
someone other than the employee.
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a Yes + Go to ltem 27
a IVo + Go to Item 29
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27 Enter the requested information for each of your marriages to someone other than the employee.
Print the most recent marriage in 27a, the second most recent in 27b, and so on.
Your Husband's or
Wife's Name and
Social Security Number
(do not show employee)
1a
Name
I
b
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a Spouse's Death Month
a Divorce
Year
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I
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Day
Year
Spouse's Death Month Day
Year
Day
Year
Ji Annulment
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C Name
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other than
Marriage Ended
(country if
other than
United States)
Date Marriage
Ended
Ended
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Name
I
Date
Married
Month Day
I
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City and State
Married
Month Day
Year
Month Day
Year
a Divorce
aAnnulment
a Spouse's Death Month
Divorce
a Annulment
1 / 1 1
28 Answer only if any of the social security numbers requested in ltem 27 are unknown. If more than one social
security number is unknown, enter the information requested in this item in Section 9 for each additional
unknown number.
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a Enter the name of the husband or wife
whose social security number is unknown.
b Enter that husband's or wife's date of birth.
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c Enter that husband's or wife's place of birth.
1 1 '
-arm AA-I 7 (10-07)
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Item 28 continues on the next oaae.
Page 4
Month
>
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Year
Day
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I
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Marriages
28 d Enter that husband's or wife's father's name.
-
e Enter that husband's or wife's mother's maiden name. +
Support
If you and the employee were divorced, go to ltem 35.
29 Enter an "X" in the appropriate box:
Q Yes
The employee and I were living together when the employee died.
If "Yes," and you are male, go to ltem 34. If "Yes," and you are female,
Q No +Go to ltem 30
go to ltem 35. o
30 Enter the date you and the employee stopped living together.
1 31
-
-
Day
Year
Enter the reason you and the employee
stopped living together.
32 Enter an "X" in the appropriate box:
The employee was making regular contributions to my support when the
employee died. If "Yes," and you are male, go to ltem 34.
If "Yes," and you are female, go to Item 35.
(Note: Consider the following as contributions to support:
money, food, clothes, paying bills, providing rent-free housing.)
*
33 Enter an "X" in the appropriate box:
The employee was under a court order to contribute to my
support.
(Note: Answer "Yes" if there was a court order, even if
the employee was not obeying it.)
Support
Month
*
Q
yes
Q No +Go to Item 33
Q Yes +Go to Item 35
Q
No +Go
to Item 35
Answer ltem 34 only if you are working or have ever worked in the railroad industry, and Items 29 or 32 was answered "Yes."
34 Enter an "X" in the appropriate box:
The employee's contributions to me provided at least
one-half of the money needed to support me.
Q Yes +Go to Note and ltem 35
a No +Go
to Item 35
Note: If answered "Yes," complete and return to the RRB,
Form G-134, Statement Regarding Contributions and Support.
Offense
35 Enter an "X" in the appropriate box:
Within the past 12 months, I have been imprisoned or given a sentence
of confinement due to a conviction for a criminal offense.
Q Yes +Go to ltem 36
Q
36 Enter the date of the conviction.
>
37 Enter the date of the sentence of confinement.
>
38 Enter the date that confinement began.
39 Enter an "X" in the appropriate box:
Has the confinement ended?
*
40 Enter the date confinement ended.
>
Page 5
+
to
Month
Day
Year
Month
Day
Year
Month
Day
Year
Yes +Go to Item 40
No +Go
Month
Day
to Section 5
Year
Form AA-17 (10-07)
Information About Applicant's Other Government Benefits
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Enter an " X in the appropriate box:
I am receiving or expect to receive a pension or I have
received or expect to receive a lump-sum payment instead
of a pension, based on my earnings, from an agency of the
Federal, state, or local government.
Service
Pub'ic
Pension
0 Yes +Go to ltem 42
0 No +Go to ltem 44
(Answer "No" if your only government pension payments
are social security, railroad retirement, veterans affairs,
worker's compensation, or black-lung benefits. Also,
answer "No" if you received a lump-sum payment that was
just your contributions to the pension fund plus interest.)
Enter an " X in the appropriate box:
I amlwas an employee of the Federal Government.
0 Yes +Go to Note and Item 44
0 No +Go to Item 43
*
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ote: If answered "Yes," complete and return to the RRB, Form G-208,
Public Service Pension Questionnaire, and verification of your pension.
Enter an "X" in the appropriate box:
In my last 60 months of employment, I was employed by a state or local
government or the militaly service, and social security (FICA)
taxes were being deducted from my public service earnings.
-
)
0 Yes + Go to Item 44
No
+ Go to Note and Item 44
I
ote: If answered "No," complete and retum to the RRB, Fonn G-208,
Public Service Pension Questionnaire, and verification of your pension.
Social
Security
Benefits
44 Enter an " X in the appropriate box:
I have filed, or plan to file, an applicationfor benefits
under the Social Secunty Act.
0 Yes +Go to ltem 45
No
45 Enter an "Xin the appropriate box:
I have filed, or plan to file, for social security benefhs
based on the record of someone other than myself.
whose account you are filing.
0 Yes +Go t o ltem 46
0 No +Go t o ltem 48
-
( 46 / Enter the name of the person on
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47 Enter that person's social security number.
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Enter an " X in the appropriate box:
I have filed, or plan to file within 90 days, an application for
monthly railroad retirement benefits based on the record of
someone other than the employee.
Railroad
Retirement
Benefits
Yes
No
+Go t o Item 49
+ Go t o Section 6
>
49 Enter an "Xuin the appropriate box:
I have filed, or plan to file, an application for railroad retirement
benefits based on my own railroad employment.
I
I
+Go t o ltem 48
r
0 Yes +Go t o Section 6
a No
-
+Go t o ltem 50
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( 50 ( Enter the name of the person on whose ]
1 1 record you have filed or will file.
/
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51 Enter that person's Railroad Retirement Board claim
number, including the letter prefix.
L
Form AA-1 7 (10-07)
Page 6
Prefix
+
If only six numbers,
enter here
Information About Work And Earnings
Please read the section "How Earnings Affect An Annuify" in Part V of the RB-17 booklet to find out how work and earnings
can affect your railroad retirement annuity. Also, please refer to Form G-77, How Earnings Affect Payment of Survivor
Annuities, for the exempt amounts to use when answering ltems 52 through 61.
Earnings
Last Year
(year)
If you were full retirement age or older when the employee died, or you are now full retirement age or older,
go to ltem 62.
Answer ltems 52 through 55 only if you were age 60 or older last year and the employee died before January 1 of this year.
52 Enter an " X in the appropriate box:
My total earnings for all employment last
year were more than the annual earnings
exempt amount shown on Form G-77.
0
* 0
53 Enter your total earnings for last year.
(SHOW DOLLARS ONLY)
>
54 Enter an " X in the appropriate box:
I earned more than the monthly earnings
exempt amount in employment for hire or
performed substantial services in
self-employment in every month last year.
(Year)
+D
Go to ltem 53
+D Go to ltem 56
Yes
No
+D
$
0
0
+D
Go to Item 56
Go to ltem 55
>
55 Enter an " X next to each month last year in
which you did not earn more than the monthly
earnings exempt amount or perform substantial
services in self-employment.
Earnings
This Year
Yes
No
~~rJg-TiK
*
~~~~
pqpJ-TqpF
Answer ltems 56 through 59 only if you are age 60 or older, or will become age 60 this year.
56 Enter an " X in the appropriate box:
I expect my total earnings for all employment
this year to be more than the annual earnings
exempt amount.
>
57 Enter the total amount that you expect to earn this year.
(SHOW DOLLARS ONLY)
>
58 Enter an " X in the appropriate box:
I expect to earn more than the monthly earnings
exempt amount in employment for hire or to perform
substantial services in self-employment in every
month this year.
Page 7
0
a
Yes
No
Go t o Item 57
+D Go to Item 60
+D
$
a Yes
a No
+D
+D
Go t o Item 60
Go t o Item 59
+
Form AA-17 (10-07)
Earnings
This Year
(Con!.)
Earnings
Next Year
59 Enter an "X" next to each month this year in which
mmmm
rTiiqmmm
you did not, or do not expect to, earn more than
the monthly earnings exempt amount or perform
substantial services in self-employment.
Answer Items 60 and 61 only if you are returning this application in September, October, November,
or December and you are age 60 or older, or will become age 60 next year.
(Year)
60 Enter an " X in the appropriate box:
I expect my total earnings for all employment
next year to be more than this year's annual
earnings exempt amount.
m Yes + Go to Itern 61
m No + Go to Item 62
>
61 Enter the total amount that you expect to earn next year.
$
>
(SHOW DOLLARS ONLY)
62 Enter an "X" in the appropriate box:
I have worked for a railroad or other
employer in the railroad industry.
m Yes + Go t o Itern 63
m No + Go to Section 7
-
63 Enter the name of your last railroad employer.
I I
1 i i 1
Mo;th
64 Enter the date you last worked for this employer.
>
65 Enter an "X" next to each month in this
year during which you worked, or you
expect to work, for an employer in the
railroad industry.
;D
Yyr
~~~~
Complete ltem 66 only if you expect your annuity to begin before January 1 of this year.
66 Enter an " X next to each month of last year during
which you worked for an employer in the railroad
industry. v
Form AA-17 (10-07)
Page 8
~~~
Beginning Dates, Filing Dates, And Medicare
Selecting a
Beginning
Date
If you are under full retirement age on the date your annuity begins, your annuity will be reduced for early retirement.
67 Enter an "X" in the appropriate box:
I want my annuity to begin on the earliest
date permitted by law, even if I will receive
a reduced annuity.
>
68 Since you do not want your annuity to begin on the
earliest date permitted by law, enter the date you want
your annuity to begin.
*
O
Yes -+ Go t o Item 69
No -+ Go t o ltem 68
r?Em
Note: If the date you select is more than 3 months after you return
jthis application, you will need to file an updated application.
Filing
Protection
Answer only if you are age 62 or older, disabled, or otherwise eligible for social security old age, disability,
or survivor benefits and you have not filed an application for such benefits.
69 Enter an "X" in the appropriate box:
I also want this application used to protect my
filing date for social security benefits.
Medicare
O
Yes
a
No
Please read the section "Medicare Benefits" in Part VIII of the RB-I7 booklet for an explanation of the Medicare program.
70 Enter an "X" in the appropriate box:
I am enrolled in the Medicare Medical
Insurance (Part B).
>
O
O
Yes -+ Go t o Item 71
No -+ Go t o Item 73
71 Enter the name of the agency where you have filed for Medicare. +
>
72 Enter your Medicare claim number.
Go t o Section 8
* O
O
Yes -+ Go t o Item 74
No -+ Go t o Section 8
74 Enter an "X" in the appropriate box:
I wish to enroll in the Medicare Medical
lnsurance (Part B).
O
O
Yes -+ Go t o ltem 75
No -+ Go t o Section 8
75 Enter an "X" in the appropriate box:
I am claiming a special enrollment period
based on coverage by an employer group
health plan.
O
O
Yes
O
O
Yes
73 Enter an "X" in the appropriate box:
I am 64 years and 5 months of age or older.
>
76 Enter an " X in the appropriate box:
I am claiming premium surcharge relief based on
coverage by an employer group health plan.
Page 9
>
No
No
Form AA-17 (10-07)
I
Direct Deposit
1 Benefits are generally paid by Direct Deposit to your bank, savings and loan, credit union, or other financial institution. To
provide the information we need to correctly deposit your payments, attach a voided personal check and go to Section 9,
or call your financial institution for the information you need to complete Items 77-81. If you do not have a bank account, or
if you believe receiving your payments by Direct Deposit would cause you a hardship, go to Item 82.
77 Enter the name of your financial institution. +
Direct
Deposit
II
.
Area Code
78 Enter the telephone number of your financial institution.
79 Enter the routing transit number of your financial institution.
-
Telephone Number
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80 Enter your account number. >
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81 Enter an " X in the appropriate box:
Type of account for the above account number.
>
a Checking
a Savings
Go t o Section 9
82 Check this box if you do not have a checking or
savings account, or if Direct Deposit would
cause you a hardship.
83 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.
Remarks
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Form AA-17 (10-07)
Page 10
Certification
Certification
Enter an "X" in the appropriate box:
I will have a guardian or other representative sign
this application on my behalf.
a Yes + Go t o Note and ltem 85
a No + Go t o ltem 85
.
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Note: If answered "Yes," your guardian or other representative
must sign this application. That person must also complete and
return Form AA-5, Application for Substitution o f Payee.
I know that if I make a false or fraudulent statement in order to receive benefits from the Railroad
Retirement Board (RRB), I am committing a crime which is punishable under Federal law.
I have received the booklet RB-17, Survivor Annuities, and the booklet, RB-Ss, Events That Affect A
SurvivorAnnuity. I understand that I am responsible for reporting any events that would affect my annuity as
explained in those booklets.
I certify that the information I gave to the RRB on this application is true to the best of my knowledge.
I agree to immediately notify the RRB:
If l remarry;
If I begin to receive a pension from an agency of the Federal, state, or local government, or
if my present payments change;
If I file for social security benefits based on any person's earnings record;
If I go to work for an employer in the railroad industry;
If I will earn more than the annual earnings exempt amount, and it was not reported on the
application;
If I reported expected earnings and my earnings estimate changes;
If my address changes;
If any person for whom I am receiving benefits dies or leaves my care;
If I am confined in a jail, prison, penal institution, or correctional institution due to a convictionfor a criminal offense.
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Signature
(First Name, Middle Initial,
Last Name)
If this certification is signed by mark ("X") in ltem 85, two witnesses who know the person signing
must sign below, giving their full addresses and daytime telephone numbers.
a Signature of Witness
Address (Number and Street)
City, State, ZIP Code
*
Daytime Telephone Number
Area Code
Telephone Number
Area Code
Telephone Number
b Signature of Witness
Address (Number and Street)
City, State, ZIP Code
*
Daytime Telephone Number
Page 11
Form AA-I 7 (10-07)
Before you return your application, check to make sure that:
*
Every question that applies to you has been answered.
*
You have entered "unknown" in any answer space for which you were unable to answer a question.
*
You have signed and dated the application.
*
You have included all the needed proofs listed in the letter you received with this application.
When you received your application, you should also have received a pre-addressed return envelope. If you
do not have this envelope, you can use any envelope as long as it is addressed to the RRB ofice shown on
page 13 of this application. No matter which envelope you use, you must put the correct postage on the envelope. Be careful to provide enough postage, because your application and the accompanying forms may weigh
more than a standard letter. The U.S. Postal Service will not deliver your application unless it has the correct
postage.
Make one final check before you seal the envelope to ensure that the following are enclosed:
*
NEEDED PROOFS
*
THE APPLICATION FORM ITSELF
*
ADDITIONAL FORMS YOU WERE ASKED TO COWIPLETE
/ Note: Make no entries on page 13, which is the receipt for your claim. After the RRB receives your
application, they will complete the blanks on the receipt and send it back to you. When it is returned to
you, you will know that the RRB has received your application and has started the work needed to
detennine if you are entitled to benefits. If you do not receive the receipt within two weeks after you filed
this application, please contact us so we can find out what is causing the delay.
'orrn AA-17 (10-07)
Page 12
)
APPLICANT'S NAME
RAILROADRmREMENT BOARD C W M NUMBER DATE CLAIM RECEIVED
Your application for a railroad retirement widow(er)'s annuity has been received and will be processed as quickly as
possible. If you do not receive your first payment by
, you should contact the servicing field office
shown below. If you change your address, or if there is some other change that may affect your claim, you or your representative should report the change. The changes to be reported are listed below. Always give us your claim number
when writing or calling about your claim. If you have any questions about your claim, we will be glad to help you. If you
need to personally visit one of our field offices, please call for an appointment. You will not be refused service if you do
not have an appointment, but our staff can serve you better when an appointment is made. Most offices are open to
the public from 9:00 AM to 3:30 PM, Monday through Friday.
a
Remarriage-If you remarry.
a month. You
(are not) earning more than $
(are) (are not) performing substantial services in selfemployment.
Report at once if work pattern changes.
a
Public Pension-If you begin to receive a pension from an agency of the Federal, state, or local
government, or if your present payments change.
a
Social Security-If you file for social security
benefits based on any person's earnings record.
a
Work-If you go to work for an employer in the
railroad industry.
a
Address-If your address changes, even if your
payments are sent to a financial organization.
a
a
Earnings-If your earnings change. On your
application you told us you expected total
. You (are)
earnings for
to be $
Widow(er) Is in Your C a r e l f any person for
whom you are receiving an annuity dies or
leaves your care.
a
Criminal Offense-lf you are confined in a jail, prison,
penal institution, or correctional facility due to a
conviction for a criminal offense.
When a change occurs after you have begun receiving your annuity, you should report the change at once. You or your
representative can make the reports by telephone, mail, or in person, whichever you prefer. In addition, an annual report
of earnings must be filed with the Railroad Retirement Board within 3 months and 15 days after the end of any taxable
year in which you earned more than the exempt amount.
The annual report of earnings is required by law and failure to report may result in the loss of one or more monthly benefits.
To report any of the above changes, contact:
b
Telephone Number:
If for some reason you cannot contact that office, you should contact:
b
U S RAILROAD RETIREMENT BOARD
844 N RUSH ST
CHICAGO IL 60611-2092
Page 13
Form AA-17 (10-07
Paperwork Reduction Act and Privacy Act Notices
This notice is given under the Papenvork Reduction Act of
1995 and the Privacy Act of 1974. The Privacy Act requires
that the Railroad Retirement Board (RRB) tell you the following whenever we ask you for information.
1) The law which allows us to ask for the information;
2) whether that law requires you to give us that information
and what, if anything, might happen to you if you do not
give
it to us;
-
3) the reason why the information is requested; and
4) the persons, organizations, and agencies to which we
may release the information without your permission.
The RRB's authority for requesting this information is
Section 7(b) of the Railroad Retirement Act of 1974.
Providing us with this information is voluntary on your part.
However, if you fail to provide us with the requested information we may be unable to pay you any benefits. The
RRB needs this information to determine whether you
are eligible to receive such benefits and, if so, the amount
you are entitled to receive. If your annuity application is
approved and we begin to pay you benefits, information
that we may request from you in the future will be used to
determine whether you are entitled to continue to receive
such benefits.
Although the information we request is almost never used
for any purpose other than the payment of benefits under
the Railroad Retirement Act, the RRB does have the
authority to release information to the indicated individuals, organizations, and/or agencies listed below without
your approval:
1) An attorney, the Office of the President, a Congressional
office, a labor union or the Department of State's embassy
or consular offices if they allege to be representing you at
your request.
Guarantee Corporation, Office of Personnel Management,
Department of Veterans Affairs, or Federal, state, or local
welfare or public aid agencies to determine if you can
receive benefits from these organizations and if any previous benefits were paid incorrectly.
8) The Internal Revenue Service or to state and local taxing
authorities for figuring your taxes and for use inaudits.
91 Your last address and the name of vour last emplover
may be released to the Department o f ~ e a l t hand 'Human
Services to be used in the Parent Locator Service.
10) The General Accounting Office for audits and for
collecting overpayments owed to the RRB or the Social
Security Administration.
11) The U.S. Department of Labor as required by the
Federal Coal Mine and Safety Act.
12) In certain cases for law enforcement purposes and for
court proceedings.
13) lnformation about the determination and recovery of
an overpayment made to you may be released to any
other person from whom any portion of the overpayment is
being recovered.
14) Your name and address may be released to a Member
of Congress to inform you about current or proposed legislation which could affect the railroad retirement system.
15) Professional Standard Review Organizations and
State Licensing Boards when services provided by
physicians or practitioners suggest unethical or
unprofessional conduct.
3) A person who will receive benefits on your behalf if the
RRB decided that some medical condition keeps you from
receiving your own benefits; such information may also be
released in determining whether such a medical condition
exists and who is suitable to receive such benefits for you.
We estimate this form takes an average Of 27 47
minutes per response to complete, including the time for
reviewina the instructions. nettinn the needed data, and
reviewing the completed foym. ~ e d e r aagencies
l
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 lnformation Resources Management,
Railroad Retirement Board, 844 North Rush Street,
Chicago, Illinois 6061 1-2092.
4) People or organizations who are working for the RRB;
such information may include medical records.
Computer Matching and Privacy Protection Act Notice
2) Other people who are receiving benefits based on the
same railroad retirement account as you are if the information affects their payments from the RRB.
5) The U.S. Treasury Department or U.S. Postal Service
to issue payments and to investigate lost, forged, or stolen
checks.
6) Your last employer to make sure that you are eligible to
receive railroad retirement benefits and you continue to
receive any available medical benefits, and to any railroad
industry employer (or to its insurance company) to make
sure that you can receive any private retirement or insurance benefits which may be offered by the employer.
7) The Social Security Administration, Centers for
Medicare & Medicaid Services, Pension Benefit
Form AA-17 (10-07)
The Computer Matching and Privacy Protection Act of
1988 requires the Railroad Retirement Board (RRB) to
advise you that information you have provided may be
used, without your consent, in automated matching
programs. These matching programs are a computer
comparison of RRB records with records kept by other
Federal, state, or local governmental agencies.
lnformation from these matching programs can be
used to establish or verify a person's eligibility for
Federally funded or administered benefit programs
and for repayment of payments or delinquent debts
under these programs.
Page 14
| File Type | application/pdf |
| File Modified | 2009-07-14 |
| File Created | 2009-07-14 |