Form AA-18 (10-07) AA-18 (10-07) Applications for Mother's/Father's and Child's Annuity

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

FORM APPROVED
O.M.B. NO. 3220-0030

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DO NOT WRITE IN THIS SPACE
,OF~Cl&YFILEDnAy

yFAR

OFFICE NUMBER
1

Application
for Mother'slFatherYs
and Child's Annuity

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APPROVED
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DATE CODED

APPLICATION NUMBER

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CODED BY

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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.
Please read 'Important Notices" on page 16 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 10 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 entering dates, always use numbers. Also, be sure there is one number in each box. For example, you would enter
February 12,2001, as:
MONTH
DAY
YEAR

012 I

2 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.
If you are completing this application on behalf of someone else, you must answer each question as it applies to the applicant.

Identifying Information
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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.
rc If the information is not correct, cross out the incorrect information and enter the correct information above it.
If the information is missing, fill it in.
Employee 1
Identification

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EMPLOYEE'S NAME

1 2 1 EMPLOYEE'S SOCIAL SECURITY NUMBER
3

EMPLOYEE'S RAILROAD RETIREMENT CLAIM NUMBER

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a-

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Applicant
4
Identification

APPLICANT'S NAME

5 a STREETADDRESS

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6

c

ZIP CODE

d

COUNTY

-

-

DAYTIME TELEPHONE NUMBER

Form AA-18 (10-07) Destroy Prior Editions

If a railroad retirement survivor benefit was previously received by someone, go to Section 4; otherwise go to ltem 7.
BirthDate

1

-

7 Enter the employee's date of birth.
- -

Residence

1

Month

1

Day

I

Year

7

- -

-

8 Enter the state (or country if other than United States) which was the
employee's permanent home at the time of death. -

If the employee was age 62 or older when he or she died, go to ltem 10.

an "X" in the appropriate box:
The employee was unable to work at the time of death because of an
~llnessor accident which occurred at least five months before death. +
Military
Service

Please read the section "Credit for Employee's Military Service" in Part V of the RB-17 booklet to find out
how active military service is determined.
10 Enter an "X"in the appropriate box:
The employee was in actwe mility service after September 7,1939.

-

Yes + Go to Note and Item 11

Q No + Go to Item I 3

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Note: If answered "Yes," you will have to submit proof of the employee's military
service. If you cannot submit proof show, in Section 10, the branch of the service
and the beginning and ending dates for each period of service.

11 Enter an "X" in the appropriate box:
The employee had voluntary military service during the
period June 15, 1948, through December 15,1950. -

Yes + Go to ltem 12

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No + Go to ltem 13

12 Enter an "X" in the appropriate box:
The employee had non-railroad earnings after leaving the
military service and before returning'to the railroad.

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Yes

Recent
13 Regardless of whether the employee was retired at death, show the name and address of each railroad or
non-railroad employer for whom the employee performed any part-time or full-time work during the last 3
Employment

years he or she worked. Print the name and address of the most recent employer in 13a, the second in 13b,
and so on. Enter the date each job began and ended.

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Name and Address of Employer

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a Name

Ended

Began

I Month I Year 1 Month 1 Year
City, State, ZIP Code

1

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b Name
Address

Began
Month

Year

1

Ended
Month

Year

City, State, ZIP Code
c Name

Began

Address

Month

Year

Ended
Month

City, State, ZIP Code
14 Enter an "X" in the appropriate box:
The employee was self-employed
during any of the last three calendar years.

Self-

Employment

-

15 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.

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Form AA-18 (10-07)

Page 2

Yes + Go to ltem 15
No + Go to ltem 17
Yes + Go to Item 16
to Item l7
+

Year

1 Self-

Employment
Con't
Railroad
Employment

1 16 Enter an " X in the a ~ ~ r o ~ r ibox(es):
ate
m

,

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,

Show the year or years in which the e;nployeels net
earnings from self-employment were more than $400.

O
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This year
Last year
Year before last

Answer ltems 17 and 18 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 ltem 19.
If the employee was alive on October 1, 1981, and had at least 25 years of railroad service, please read the
section "Requirementsthe Employee Must Have Met" 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 verify the statements
made in ltems 17 and 18.
17 Enter an " X in the appropriate box:
The employee "involuntarily and without fault":

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.

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O
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18 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 ltem 18
No + Go to ltem I 9

O
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Yes
No

Employee's 19 Enter the requested information for each of the employee's marriages. Enter the most recent marriage in 19a,
Marriages
the second most recent in 19b, and so on.

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Answer if Marriage Ended for Reason

Name of Employee's Wife
or Husband
(if wife, include
maiden name)

a

b

C

City and State
Married
(country if other
than United States)

Date
Married
Month Day

Year

Month Day

Year

Month Day

Year

How Marriage
Ended
(check one)

City and State
Marriage Ended
(country if other
than United States)

Date Marriage
Ended

Employee's Death Month
Day Year
O Spouse's Death
O Divorce
O Annulment
Employee'SDeath
~~~~h D~~ year
O Spouse's Death
O Divorce
O Annulment
Employee's Death Month
Day

Year

O Spouse's Death
O Divorce
O Annulment

Answer ltem 20 only if you and the employee were divorced.
Please read the marriage requirements in Part I11 of the RB-17 booklet to find out what categories of
widow(er)s may be eligible for a railroad retirement annuity.
20 Enter an " X in the appropriate box:
There is a widow(er) or remarried widow(er) who may be eligible
for a widow(er)'s annuity.
Page 3

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0
O

Yes
No
Form AA-18 (10-07)

Parents

21 Enter an "X" in the appropriate box:
The employee was survived by a parent.

a Yes + Go to Item 22
a No + Go t o Section 4
a Yes + Go t o Item 23
a No +Go t o Section 4

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22 Enter an "X" in the appropriate box:
The parent was dependent on the employee
- for one-half of his or her support.

1 23 Enter the requested information for each dependent parent of the employee.
Name of Parent
1 Date of Birth I Address and Telephone Number
a

Month

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Day

I Year
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Telephone Number (include area code)
(

Month

)

Year Address
Day Telephone Number (include area code)

Information About The Applicant
Birth Date

24 Enter your date of birth.

25 Enter your social security number.
(If none, enter "To be submitted.")

Security
Number

Month

Dav

Year

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d

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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 t o ltem 27
a No + Go t o ltem 29

27 Enter the requested information for each of your marriages t o someone other than the employee.
Enter the most recent marriage in 27a1the second most recent in 27b1and so on.

Your Husband's or
Wlfe's Name and
Social Security Number
(do not show employee)
a

Name

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Name

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Month Day Year

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C Name

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Month Day Year

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Spouse's Death Month Day

OD'lvorce

aAnnulment
a Spouse's Death Month

Year

Day

Year

Spouse's Death Month Day

Year

IJDivorce
IJAnnulment
IJ Divorce

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Marriage Ended
(country if
other than
United States)

Date Marriage
Ended

Ended

other than

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b

Date
Married
Month Day Year

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City and State
Married

Annulment

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 in Section 9, the information requested in this item for each additional
unknown number.
a Enter the name of the husband or wife
whose social security number is unknown. P
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.

-18 (10-07)

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ltem 28 continues on the next page.
Page 4

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1

Month

:D

Ygar

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Marriages

28 d Enter that husband's or wife's father's name.

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e Enter that husband's or wife's mother's maiden name. +
If you and the employee were divorced, go to ltem 35.
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29 Enter an " X in the appropriate box:
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,
go to ltem 35.
30 Enter the date you and the employee stopped living together.

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31 Enter the reason you and the employee
stopped living together.

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No

+Go t o ltem 30

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Month

1

Day

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Year

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32 Enter an "Xin 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.
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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 "Xin the appropriate box:
The employee was under a court order to contributeto my
support.
(Note: Answer "Yes" if there was a court order, even if
the employee was not obeying it.)
support

Yes

Yes
No +Go

t o ltem 33

Yes +Go t o ltem 35

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Answer ltem 34 only if you are working or have ever worked in the railroad industry, and Items 29 or 32 was answered 'Yes."
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34 Enter an "X" in the appropriate box:
The employee's contributions to me provided at least
onehalf of the money needed to support me.

Yes +Go to Note and Item 35
No +Go

t o ltem 35

Note: If answered "Yes,"complete and return to the RRB,
Form 6-134, Statement Regarding Contributions a n d Support.

Offense

35 Enter an " X in the appropriate box:
Within the past 12 months, I have been imprisoned or given a
sentence of confinementdue to a conviction for a criminal offense.
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.

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Yes +Go to ltem 36
No -+Go t o Section 5
Month

Day

Year

Month

Day

Year

Month

Day

Year

Yes +Go to Item 40
No +Go
Month

Day

to Section 5
Year
Form AA-18 (10-07)

Information About Children
Please read the section "Definifion of a Child's Annuity" in the RB-17 booklet to find out what categories of children may
be eligible for a railroad retirement annuitv.
Children

41 Print the requested information for every child for whom you are filing this application who may be entitled
to a child's annuity. Print the youngest child in a, the second youngest in b, and so on. Always complete f.
If a child does not have a social security number, enter "TO BE SUBMITTED."
Child's Full Name and
Social Security Number
a Name
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Relationship to Employee
(Check One)

O
O
O
O

Natural
Adopted
Stepchild
Grandchild
Other

a

b Name

O Natural

c Name

a
a
a
a

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e Name

f

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Children

Not Living
With
Applicant

Legal
Guardian

Day

Yes

Year

O
Month

Day

Month

Day

No

a Yes

Year

O

Natural
Adopted
0 Stepchild
Grandchild
O Other

No

Yes

Year

a No

Natural
Adopted
Stepchild
Grandchild
Other

a
a
a
a

Date of Birth
Month

Adopted
Stepchild
Grandchild
Other

d Name

Enter an "X" in the
Appropriate Box: The
Child is Living with Me

Month

Day

Yes

Year

a No

Natural
Adopted
O Stepchild
Grandchild

Month

Day

a Yes

Year

I I I I I I I

Within the past 12 months, a child named in a through e above has been imprisoned, or
given a sentence of confinement due to a conviction for a criminal offense. If the answer is
"Yes," a full explanation, including the name of the child, must be provided in Section 10.-

O

No
Yes
No

If every child in ltem 41 is living with you, go t o ltem 43.
42 Print the requested information for every child in ltem 41 who is not living with you. Print the youngest child in 42a.
If you need more space use Section 10.
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First Name
of Child

Person with Whom Child now Lives
Child's Address

43 Enter an " X in the appropriate box:
A court has appointed a legal guardian for a child in ltem 41.

Form AA-18 (10-07)

Page 6

Name

-

Relationship to Child

a Yes +Go t o Item 44
a No +Go t o ltem 45

Legal
Guardian
Con't

44 Print the requested information for every child in Item 41 who has a court-appointed legal guardian.
Print the youngest child in 44a, etc.
First Name of Child

Name and Address of Guardian

a

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b

Children

m Yes +Go to ltern 46
m No +Go to ltern 47

45 Enter an " X in the appropriate box:
One or more of the children in ltem 41 is or
has been married.

46 Print the requested information for every child in ltem 41 who has ever been married.
Print the youngest child in 46a, etc.
Date Marriage Ended
Enter an "X" in the
Child's
if Child Is Not
Appropriate Box:
Date Married
Married Name
Still Married
The Child Is Still Married
Year
Month Day
Year
Month Day
a
Yes
NO

m

Month

b

GrandChildren,
Other
Children

Day

Year

a Yes m No

Month

Day

Year

If "Natural" or "Adopted" was checked for every child in Item 41, go to Item 49.

m Yes +Go to ltem 49
m No +Gotoltem48

47 Enter an "X" in the appropriate box:
Every "Grandchild" or "Other Child" in ltem 41 was living
with the employee at the time the employee died.

48 Print the requested information for every "Grandchild or "Other Child" in ltem 41 who was not living with the employee
at the time the employee died. Print the youngest child in 48a, etc. If you need more space use Section 10.
First Name
of Child

Person with Whom Child Lived at the Time the Employee Died
Name

Relationship to Child

Address

a

b

Children
For Whom
YOU Are
Not Filing

49 Enter an " X in the appropriate box:
There is a child for whom I am not filing this
application who may be entitled to a child's annuity.

m Yes +Go to ltem 50
m No +Go to Item 51

50 Print the requested information for every child for whom you are not filing an application who may be entitled
to a child's annuity. Print the youngest child in 50a, the next youngest in Sob, and so on.
Child's Full Name

Reason for Not Filing

a

b

C

Page 7

Form AA-18 (10-07)

1

Information About Applicant's Other Government Benefits
Public
Service
Pension

51 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.

0 Yes + Go t o ltem 52

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a No

(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.)

+Go t o ltem 54

a Yes +Go to Note and Item 54
a No +Go t o Item 53

52 Enter an " X in the appropriate box:
I amlwas an employee of the Federal Government.
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Note: If answered "Yes," complete and return to the RRB, Form G-208,
Public Service Pension Questionnaire, and verification of your pension.

53 Enter an "X" in the appropriate box:
On my last day of employment, I was employed by a state or local
government or the military service, and social security (FICA)
taxes were being deducted from my public service earnings.

-

a Yes + Go t o Item 54
a No + Go to Note and Item 54

Note: If answered "No," complete and return to the RRB, Form G-208,
Public Service Pension Questionnaire, and verification of your pension.
Social
Security
BenefitsFiled For

54 Enter an "X" in the appropriate box:
An application has been filed for monthly social security
benefits for me or a child.

0 Yes -+Go t o Item 55

a No

+Go t o ltem 56

55 Enter the requested information for every family member for whom an application has been filed for
monthly social security benefits. Use as many lines as are needed beginning with 55a.
Family
Member

Social Security Number
Filed On

Person Whose
Record Was Filed On

a

b

C

Social
Security
BenefitsFuture
Filing

a Yes +Go t o Item 57
a No +Go t o ltem 59

56 Enter an " X in the appropriate box:
An application will be filed in the future for monthly
social security benefits for me or a child.

-

57 Enter the name of the person on
whose record you are filing.

58 Enter that person's social security number.
Form AA-18 (10-07)

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Page 8

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Railroad
Benefits

59 Enter an "X" in the appropriate box:
An application has been or will be filed within 90 days for
monthly railroad retirement benefits for me or a child based on the
record of someone other than the employee.

Yes
No

+

a Yes +Go t o ltem 61

60 Enter an "X" in the appropriate box:
The application has been or will be filed based on the record of
someone other than myself.
61 Enter the name of the person on
application has been or will be filed.

No +Go to Section 7

-

62 Enter that person's Railroad Retirement Board claim
number, including the letter prefix.

+Go to Item 60
+Go to Section 7

If only six numbers,
enter here

Prefix

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Information About Work And Earnings
Please read the section "How Earnings Affect An Annuity" in Part V of the RB-17 booklet to find out how work and earnings
can affect your railroad retirement annuity or a child's annuity. Also, please refer to Form G-77, How Earnings Affect
Payment of Survivor Annuities, for the exempt amounts to use when answering ltems 63 through 69. When answering
ltems 63 through 71, consider only yourself and the children listed in ltem 41.
Earnings
Last Year

(Year)

Answer Items 63 and 64 only if the employee died before January 1 of this year.
63 Enter an "X" in the appropriate box:
My total earnings, or the total earnings of a child, for all
employment last year were more than the annual earnings
exempt amount shown on Form G-77.

a Yes + Go t o Item 64
a No + Go t o ltem 65

64 Print the requested information for every family member whose total earnings for last year were more than the
annual earnings exempt amount shown on Form G-77. Use as many lines as needed beginning with 64a.
2 Total Earnings for Last Year
(Show Dollars Only)

a 1 Family Member

3 Enter an "X" in the appropriate box:
The family member earned more than the monthly earnings
exempt amount in employment for hire or performed substantial
services in self-employment in every month last year.

-

tl Yes
tl No

4 Enter an "X" next to each month last year in
which the family member did not earn more than
the monthly earnings exempt amount or perform
substantial services in self-employment.
2 Total Earnings for Last Year
(Show Dollars Only)

b 1 Family Member

3 Enter an "X" in the appropriate box:
The family member earned more than the monthly earnings
exempt amount in employment for hire or performed substantial
services in self-employment in every month last year.

-

tl Yes

cl No

4 Enter an "X" next to each month last year in
which the family member did not earn more than
the monthly earnings exempt amount or perform
substantial services in self-employment.
Page 9

Form AA-18 (10-07

Earnings
Last Year
Con't

(Year)

c 1 Family Member

2 Total Earnings for Last Year
(Show Dollars Only)
$

3 Enter an "X in the appropriate box:
The family member earned more than the monthly earnings
exempt amount in employment for hire or to performed substantial
services in self-employment in every month last year.
4 Enter an " X next to each month last year in

Earnings
This Year

(Year)

-

a Yes
O IVo

rlJANmmmmrTG
rlJULIlSEpIrTiq-Tqrn

which the family member did not earn more than
the monthly earnings exempt amount or perform
substantial services in self-employment.
65 Enter an "X in the appropriate box:
Yes -+ Go to Item 66
I expect my total earnings, or the total earnings of a child
for all employment this year to be more than the annual NO -+ GO to Item 67
earnings exempt amount.
66 Enter the requested information for every family member whose total earnings for this year are expected to
be more than the annual earnings exempt amount. Use as many lines as needed beginning with 66a.
2 Total Expected Earnings for This Year
a 1 Family Member
(Show Dollars Only)
$

a
a

3 Enter an " X in the appropriate box:
The family member expects 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.

a yes
O No

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4 Enter an " X next to each month this year in which the

family member did not, or does not expect to, earn
more than the monthly earnings exempt amount or
perform substantial services in self-employment.

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2 Total Earnings for This Year
(Show Dollars Only)
$

b 1 Family Member

~~~~~~

3 Enter an "X" in the appropriate box:
The family member expects 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.
4 Enter an " X next to each month this year in which the

family member did not, or does not expect to, earn
more than the monthly earnings exempt amount or
perform substantial services in selfemployment.

a Yes
O No

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c 1 Family Member

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2 Total Earnings for This Year
(Show Dollars Only)
$

3 Enter an "X"in the appropriate box:
The family member expects 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.
4 Enter an "X next to each month this year in which the

family member did not, or does not expect to, earn
more than the monthly earnings exempt amount or
perform substantial services in self-employment.

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[7 Yes
[7 No

mmmmmm
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Note: If there are two or more children qualified to receive benefits and you are earning more than
the annual earnings exempt amount, please contact the RRB field office. Someone will be able to
help you decide whether it is better for you to file for yourself and the children, or whether you would
actually be better off to file for the children alone.
Form AA-18 (10-07)

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Page 10

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Earnings
Next Year

(Year)

67 Enter an "X in the appropriate box:
I am returning this application in September,
October, November or December.

*

68 Enter an "X" in the appropriate box:
I expect my total earnings, or the total earnings of
a child, from all employment next year to be more
than the annual earnings exempt amount.

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a Yes + Go t o ltem 68
a No + Go t o ltem 70
a Yes + Go t o Item 69
a NO + Go t o ltem 70

69 Enter the requested information for every family member whose total earnings for next year are expected to be
more than the annual earninas exem~tamount. Use as manv blanks as are needed beainninn
- with 69a.

-

Family
Member

Railroad
Work

Expected Earnings
for Next Year
(Show Dollars Only)

-

Expected Earnings
for Next Year
(Show Dollars Only)

Family
Member

Family
Member

Expected Earnings
for Next Year
(Show Dollars Only)

a
a

70 Enter an "X" in the appropriate box:
Yes + Go t o ltem 71
I have worked, or a child has worked, for a railroad
No + Go t o Section 8
or other employer in the railroad industry.
71 Enter the requested information for every family member who has worked for a railroad or other employer
in the railroad industry. Use as many lines as needed beginning with 71a.
2 Railroad Employer
3 Date Last Worked
a 1 Family Member
Month

1

Day

I

4 Enter an ' X next to each month in this year during
which the family member worked for an employer in
the railroad industry.

*

5 If you expect the annuity to begin before January 1
of this year, enter an " X next to each month of last
year during which the family member worked for an
>
employer in the railroad industry.
b 1 Family Member

5 If you expect the annuity to begin before January 1
of this year. enter an "X next to each month of last
year during which the family member worked for an
employer in the railroad industry.
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Year

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rlqJULrTqmrJGJm
3 Date Last Worked

2 Railroad Employer

4 Enter an " X next to each month in this year during
which the family member worked for an employer in
t
the railroad industry.

c 1 Family Member

~

I

1

mmrnmmm
I ~1 ~ ~
rpqJULrnmrTqm
JAN

2 Railroad Employer

3 Date Last Worked
Month

1

I

Day

I

Year

I

4 Enter an ' X next to each month in this year during
which the family member worked for an employer in
the railroad industry.

5 If you expect the annuity to begin before January 1
of this year, enter an "X next to each month of last
year during which the family member worked for an
employer in the railroad industry. P
Page 11

Form AA-18 (10-07)

--

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.
72 Enter an "X in the appropriate box:
I also want this application used to protect my
filing date for social security benefits.

a Yes
a No

>

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 t o Section 10,
or call your financial institution for the information you need to complete Items 73-77. If you do not have a bank account, or
receiving your payments by Direct Deposit would cause you a hardship go to Item 78.
Direct
Deposit

73 Enter the name of your financial institution.

+

-

AREA CODE

74 Enter the telephone number of your financial institution.

75 Enter the routing transit number of your financial institution.

1

TELEPHONE NUMBER

I I I I I I I I I

76 Enter your account number. >
I

Q Checking

77 Enter an " X in the appropriate box:
Type of account for the above account number.

>

-

78 Check this box if you do not have a checking or savings account,
or if Direct Deposit would cause you a hardship.

Remarks
Remarks

Q Savings
Go t o Section 10

0

79 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.

-arm AA-18 (10-07)

Page 12

1

Certification
Certification

a Yes
a No

80 Enter an "X" in the appropriate box:
I will have a guardian or other representative sign
this application on my behalf.

-+ Go to Note and ltem 81
-+ Go to ltem 81

I

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 of Payee.
81 1 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 RE-17, Survivor Annuity, and the booklet, RE-Ss, Events That Affect A Survivor
Annuity. I understand that I am responsible for reporting any events that would affect my annuity as explained in
those booklets.

I

I

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 marry;
If I begin to receive a pension from an agency of the Federal, state, or local government, or if my
present payments change;
If an application is filed for social securii benefits for me or any child based on any person's earnings record;
If I or any child go to work for an employer in the railroad industry;
If I or any child will earn more than the annual earnings exempt amount, and it was not reported on the
application;
If I reported expected earnings for myself or any child and that earnings estimate changes;
If my address changes;
If any child for whom I am receiving benefits dies, marries, or leaves my care;
a If I am, or any child is, confined in a jail, prison, penal institution, or correctional institution due to a conviction
for a criminal offense.
I
I
Signature
(First Name, Middle Initial,
Last Name)
Date

I

Month

I

Dav

I

Year

**

82 If this certification is signed by mark ("Xu)in ltem 81, 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 (include area code)

-

Area Code

Telephone Number

-

Area Code

Telephone Number

b. Signature of Witness

Address (Number and Street)
City, State, ZIP Code

Daytime Telephone Number (include area code)

Page 13

Form AA-18 (10-07)

I

How To Return Your Application
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 office shown on
page 15 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:

f

*

NEEDED PROOFS

*

THE APPLICATION FORM ITSELF

*

ADDITIONAL FORMS YOU WERE ASKED TO COMPLETE

Note: Make no entries on page 15, 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
determine if you are entitled to benefits. If you do not receive the receipt within two weeks affer you filed
this application, please contact us so we can find out what is causing the delay.

Form AA-18 (10-07)

Page 14

Employee's Name

Applicant's Name

Railroad Retirement Board Claim Number

I

Date Claim Received

I

Your application for a railroad retirement mother'slfather's and child's annuity has been received and will be processed as
, you should contact the servicing field
quickly as possible. If you do not receive your first payment by
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.

Marriage-If you marry.

Child E a r n i n g c l f any child's total earnings or selfemployment status changes from what was reported on
this application.

* Public Pension-If

you begin to receive a pension
from an agency of the Federal, state, or local govern
ment, or if your present payments change.

Work- If you or any chlid go to work for an employer in the
railroad industry.

Social Security-If an application is filed for social
security benefits for you or a child based on any person's earnings record.
Address-If your address charlges, even if your payments are sent to a financial organization.
Earnings-If your earnings change. On your application
you told us you expected total earnings for
to be
.
You
(are)
(are
not)
earnirlg
more
than
$
a month. You (are) (are not) performing
4$
substantial services in self-employment.

Applicant is i n Your Care-If any person for
whom you are receiving an annuity dies marries, or
leaves your care.
Criminal Offense-If you or any child are confined in a
jail, prison, penal institution, or correctional facility due
to a conviction for a criminal offense.

Report at once if work pattern changes.

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:
Railroad Retirement Board
Office of ProgramsIPolicy & Systems
844 North Rush Street
Chicago, 111. 60611-2092
Telephone Number: (312) 751-4500

If for some reason you cannot contact that office, you should contact:

U S RAILROAD RETIREMENT BOARD
844 N RUSH ST
CHICAGO IL 60611-2092
Page I 5

Form AA-18 (10-07)

Paperwork Reduction Act and Privacy Act Notices
This notice is given under the Papetwork 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.

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.

1) The law which allows us to ask for the information;

8) The Internal Revenue Service or to state and local taxing
authorities for figuring your taxes and for use in audits.

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:
I ) 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.

9) Your last address and the name of your last employer may
be released to the Department of Health and 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 to 47 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 lnformation Resources
Management, Railroad Retirement Board, 844 North Rush
Street, Chicago, Illinois 6061 1-2092.

4) To 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 Guarantee Corporation,
Form AA-18 (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 I 6