AA-20 (10-07) Applicationfor Parent's Annuity

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UNITED STATES OFAMERICA
RAILROAD RETIREMENT BOARD

FORM APPROVED

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O.M.B. NO.3220-0030

DO NOT WRITE IN THIS SPACE
OFFICIALLY FILED
MONTH I
DAY

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YEAR

OFFICE NUMBER

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Application
for
Parent's Annuity

APPROVED

DATE CODED
MONTH

APPLICATION NUMBER

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DAY

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CODED BY

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YEAR

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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 12 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,
2000, as:
MONTH

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.

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Identifying Information

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1

Check the information entered by the Railroad Retirement Board (RRB) for Items 1 through 6 for accuracy.
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.
> If the information is missing, fill it in.

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1

Identification

EMPLOYEE'S NAME

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2 EMPLOYEE'S SOCIAL SECURITY NUMBER

1 3 1 EMPLOYEE'S RAILROAD RETIREMENT CLAIM NUMBER

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Applicant
Identification 4

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APPLICANT'S NAME

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CITY AND STATE

c

ZIP CODE

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1 1
6

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b

COUNTY

DAYTIME TELEPHONE NUMBER

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Form AA-20 (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.
"lth Oate

1 7 1 Enter the employee's date of birth.

Residence

Month

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Day

Year

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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.

a

Disability

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Militaly

9 Enter an "Xin the appropriate box:
Yes
The employee was unable to work at the time of death because of an
- ..
U No
I illness or accident which occurred at least five months before death.
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Please read the section "Credit for Employee's Militaly Service" in the RB-17 booklet to find out how active
military service is determined.

-a Yes

Enter an " X in the appropriate box:
The employee was in active military service after
September 7, 1939.

UNo

--

Go to Note and ltem 11
Gotoltem13

Note: If answered "Yes,"you will have to submit proof of the employee's milita
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.
Enter an " X in 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.
Recent

Employment

a Yes
No

>

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Go to ltem 12
Go to ltem 13

Yes

>

tl 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 13a, the second in 13b, and so on.
Enter the date each job began and ended.
Name and Address of Employer

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Name

1

Began

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Address

Ended

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Year

Month

Year

Month

City, State, ZIP Code

1
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Name
Address

Began
Month

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Year

1
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Ended
Month

1

Year

City, State, ZIP Code
Name
Address

City, State, ZIP Code
Self14 Enter an " X in the appropriate box:
Employment
The employee was self-employed during any of the
last three calendar years.

Ended

Began
Month

Year

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15 Enter an "Xuin the appropriate box:
The employee's net earnings from self-employment were more
than $400 in any of the last three calendar years.
=arm AA-20 (10-07)
Page 2

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Month

Year

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a Yes Go to ltem 15
a No Go to ltem 17
a Yes -+ Go to ltem 16
a No + Go to ltem 17

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Self16 Enter an " X in the appropriate box(es):
Employment
Show the year or years in which the employee's net
(Continued)

earnirrgs from self-employment were more than $400.

a This year
a Last year
a Year before last

Answer ltems 17 and 18 only if the employee was alive on October I,1981, and he or she had at least 25 years

Employment of railroad service; otherwise go to Itern 19.

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 Mef" in Part Iof the RB-17 booklet to find out what special conditions
may apply.
ote: You may be requested to submit proof to verilj/ the statemen
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 I , 1975, or
was on furlough, leave of absence status, or absent because
of injury on October I,1975, and was never called back to
work for that employer.

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Yes + Go t o Itern 18
No + Go t o Section 4

a Yes

Enter an "Xuin 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 railroadjob.

a No

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Information About The Employee's Family
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Please read the section "Definitionof a Widow(er)'sAnnuity" in Part I1of the RB-17 booklet to find out what
categories of widow(er) may be eligible for a railroad retirement annuity.

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19 Enter an " X in the appropriate box:
There is a widow(er), remarried widow(er), or surviving divorced
spouse who may be eligible for a widow(er)'s annuity.
Children

a Yes
a No

Please read the section "Definitionof a Child's Annuity" in Part I1of the RB-I 7 booklet to find out what categories
of children may be eligible for a railroad retirement annuity.
20 Enter an " X in the appropriate box:
There are children who may be eligible for an annuity.

a Yes
a No

Answer Item 21 only if the employee was male.
21 Enter an "X" in the appropriate box:
A child of the employee is expected to be born.

Birth Date

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a Yes
a No

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22 Enter your date of birth.

?

Relationship 23 Enter an " X in the appropriate box:

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I am the employee's only living natural parent,
stepparent, or adoptive parent.

Enter an "X" in one box only to show your
relationship to the employee.

>

Page 3

a Yes
a No

a Natural Parent
a Stepparent
a Adoptive Parent

+
+

Go to Itern 29
Go to Itern 25

+ Go to Itern 26
Form AA-20 (10-0;

1

Enter the date of your marriage to the employee's
natural mother or father.

Parent

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1 1 1 1
Mo,nth

Adoptive
Parent

Enter the place (city and state or foreign country)
where you adopted the employee.

;D

Go to Itern 29

Y
re;

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Year
Month
Day -

Enter the date of the adoption.

Enter the name of the court which issued the
adoption decree.

+

Enter an "X" in the appropriate box:
The employee was contributing at least one-half of the money and
goods needed to support me at the time the employee died or at
the beginning of the employee's period of disability if he or she
had one. (Consider the following as contributions to support:
money, food, clothes, paying bills, providing rent-free housing.)

C1 Yes +Go to Note and Item 30
C1 No +Go to Section 11

Note: If answered "Yes,"you will have to complete and return to the RRB,
Form 6-134, Statement Regarding Contributions and Support.
Enter an " X in the appropriate box:
I remarried after the employee's death.

a Yes +Go to Item 31
a No +Go to Itern 32

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31 Enter the requested information for each of your marriages after the employee's death. Print the most recent
marriage in a, the second most recent in b, and so on.
How Marriage Ended
(Check One)
Date
Married

Your Husband's or
Wife's Name

(If Marriage Never Ended
Leave Blank)

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a

Month

Day

Spouse's death

Year

C1
b

1

Month

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a
a
a
a
a
a

Year

1 Month

C

Social
Security
Number
Criminal
Offense

Day

If none enter "TO BE SUBMITTED."

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Enter an "X" in the appropriate box:
Within the past 12 months, I have been imprisonedor given a sentence
of confinement due to a conviction for a criminal offense.
34 Enter the date of the conviction.

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35 Enter the date of the sentence of confinement.

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Form AA-20 (10-07)

Day

Page 4

Year

Annulment
Spouse's death
Divorce
Annulment
Spouse's death
Divorce
Annulment

a Yes +Go to ltem 34
C1 No

+ Go

to Section 6

Month

Day

Year

Month

Day

Year

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Month
Year
Day -

Criminal
36 Enter the date that confinement began.
Offense
(Continued)

37 Enter an "X" in the appropriate box:
Has the confinement ended?

m Yes + Go t o Item 38
m No + Go t o Section 6

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38 Enter the date confinement ended.

Month

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1

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Day

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Year

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lnformation About Applicant's Other Government Benefits
Social
Security
Benefits

39 Enter an "X" in the appropriate box:
I have filed, or plan to file, an application for benefits
under the Social Security Act.

>

40 Enter an " X in the appropriate box:
I have filed, or plan to file, for social security benefits based on
someone other than myself.

>

1 41 1 Enter the name of the person on whose account
I you are filing.

m Yes +Go t o ltem 40
m No +Go t o ltem 43
m Yes +Go to ltem 41
m No +Go to ltem 43

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1 42 1 Enter that person's social security number.
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43 Enter an "X" in the appropriate box:
Railroad
Retirement
I have filed, or plan to file within 90 days, an application for
Benefits

monthly railroad retirement benefits based on someone other
than the employee.

45 Enter the name of the person on whose record
you have filed or will file.

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If only six numbers, enter he

Prefix

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

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m Yes +Go t o Item 44
m No +Go t o Section 7
m Yes +Go t o Section 7
m
to Item
45

44 Enter an " X in the appropriate box:
I have filed, or plan to file, an application for railroad retirement
benefits based on my own railroad employment.

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lnformation 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.
If you were age 70 or older when the employee died, or you are now age 71 or older, go t o ltem 58, Railroad Work.
When answering ltems 47 through 57, refer to Form G-77, How the Amount o f Earnings Affects Payment o f Survivor
Annuities, for the exempt amount to use.
If the employee died January 1 or later of this year, skip ltems 47-50 and go t o ltem 51, Earnings This Year.
Earnings
Last Year
(Year)

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47 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.

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m Yes Go t o ltem 48
m No +Go to ltem 51
+

48 Enter your total earnings for last year.
(SHOW DOLLARS ONLY)

49 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.

m Yes +Go t o Item 51
m No +Go t o Item 50

+
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Page 5

Form AA-20 (10-

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Earnings
Last Year
(Continued)

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

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.

Q Yes + Go to ltem 52
Q No

>

+ Go to ltem 55

(Year)

Enter the total amount that you expect to earn this year.

>

(SHOW DOLLARS ONLY)

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53 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.

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Earnings
Next Year

Q No

Q Yes + Go to ltem 56
Q No

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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. >

Enter an " X in the appropriate box:
I have worked for a railroad or other employer in the
railroad industry.

59 Enter the name of your last railroad employer.

+ Go to ltem 58

Q Yes + Go to ltem 57
Q No + Go to ltem 58

Enter the total amount that you expect to earn next year.
(SHOW DOLLARS ONLY)
Railroad
Work

+ Go to Item 54

Enter an " X next to each month this year in which you did
not, or do not expect to, earn more than the monthly earnings exempt amount or perform substantial services in
self-employment.
Enter an " X in the appropriate box:
I am returning this application in September, October,
November, or December.

(Year)

Q Yes + Go to ltem 55

>

$

+

Q Yes + Go to ltem 59
Q No + Go to Section 8

+

Enter the date you last worked for this employer.

-

Month

1

Day

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Year

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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. v

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Complete ltem 62 only if you expect your annuity to begin before January 1 of this year.
62 Enter an "X" next to each month of last year
during which you worked for an employer in
the railroad industry.

1 1
=arm

AA-20 (10-07)

>I~OIJUNIOJUL~
Page 6

Filing Date And Medicare
Answer Item 63 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.

Filing

a Yes

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

a No

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Medicare

-

-

-

-

Please read the section "Medicare Benefits" in Part Vlll of the RB-17 booklet for an explanation of the
Medicare program.
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Enter an " X in the appropriate box:
I am enrolled in the Medicare medical insurance (Part B).

a Yes

B No +

Go t o ltem 65
Go to ltern 67

Enter the name of the agency where you have filed for Medicare.

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66 Enter your Medicare claim number.

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Enter an "Xin the appropriate box:
I am 64 years and 5 months of age or older.

*

Enter an " X in the appropriate box:
I wish to enroll in Part B.

>

Enter an " X in the appropriate box:
I am claiming a special enrollment period based on coverage
by an employer group health plan.
Enter an " X in the appropriate box:
I am claiming premium surcharge relief based on coverage by
an employer group health plan.

-

Go To Section 9
Yes

D No
B Yes
Q No

L

-

B Yes
D No

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B Yes
D No

I

+ Go to ltern 68
Go t o Section 9

+ Go to ltem 69

+

Go t o Section 9

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 71-75. If you do not have a bank account, or
receiving your payments by Direct Deposit would cause you a hardship, go t o ltem 76.
Direct
Deposit

Enter the name of your financial institution. 4
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Area Code

72 Enter the telephone number
for your financial institution.
financial institution.
Enter your account number.

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

~
B

+

Checking

Q Savings
Go t o Section 10

Check this box if you do not have a checking
or savings account, or if Direct Deposit would
cause you a hardship.
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+
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Page 7

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Form AA-20 (1 0-07)

Remarks
Remarks

Form AA.

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.

07)

Page 8

Certification
Certification 78 Enter an " X in the appropriate box:
Yes + Go to Note and ltem 79
Iwill have a guardian or other representative sign
No + Go t o Itern79
this application on my behalf. 9

a

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
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, SurvivorAnnuities, and the booklet RB-Ss, Events That AffectA
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 I marry;
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 Iwill 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 conviction for a
criminal offense.
Signature
(First Name, Middle Initial,
Last Name)

+

Date
If this certification is signed by mark ("X) in ltem 79, two witnesses who know the person signing must sign
below, giving their full addresses and daytime telephone numbers.
a Signature of Witness

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

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1

Daytime Telephone Number

Area Code

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Telephone
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Number

Area Code

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Telephone Number

b Signature of Witness

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

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Daytime Telephone Number
Page 9

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Form AA-20 (10-07

1

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 includedall 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 11 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 COMPLETE

/ Note: Make no entries on page 11, which is the receipt for your claim. ARer 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 after you
\filed this application, please contact us so we can find out what is causing the delay.

orm AA-20 (10-07)

Page 10

EMPLOYEE'S NAME

APPLICANT'S NAME

RAILROAD RETIREMENT BOARD CLAIM NUMBER

DATE CLAIM RECEIVED

Your application for a railroad retirement parent's annuity has been received and will be processed as quickly as possible. If
, you should contact the servicing field ofice shown below. If
you do not receive your first payment by
you change your address, or if there is some other change that may affect your claim, you or your representativeshould
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.

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

Marriage-If you marry.
Social Security-If you file for social security benefits based on any person's earnings record.
Earnings-If your earnings change. On your application you told us you expected total earnings for
to be $
.You (are) (are not) earning more
than $
a month. You (are) (are not) performing substantial services in self-employment.
Report at once i f work pattern changes.

Address-If your address changes, even if your payments are sent to a financial organization.
Parent Is In Your Care-If any person for whom you
are receiving an annuity dies or leaves your care.
a

Criminal Offense-If 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

S 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 lL 60611-2092
Page 11

Form AA-20 (10-07

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

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, organi;ations,
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 RetirementAct of 1974. Providing us with
this information is voluntary on your part. However, if you fail to
provide us with the requested informationwe 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 RetirementAct, 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.
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.
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.

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) Information 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.

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
60611-2092.
Computer Matching and Privacy Protection Act Notice

4) People or organizations who are working for the RRB;
such information may include medical records.
5) The U.S. Treasury Department or U.S. Postal Service to
issue checks 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.

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 Federa, 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 ,oroarams.

7) The Social Security Administration, Centers for
Medicare & Medicaid Services, Pension Benefit
Guarantee Corporation, Office of Personnel Management,
Form AA-20 (10-07)

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