AA-17cert (Sample Application Summary and Certification

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United States of America
Railroad Retirement Board

Form
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APPLICA'TION SUMMARY and CERTIFICATION

Elizabeth X'*'KXk
A 329. X x - ' k x X ' ~

Employee's Name
RR Claim No.

The following information was either supplied by or verified by you in support of your
application for a Widow(er)'s Annuity under the Railroad Retirement Act. After you have
reviewed the information, make any changes on the summary, initial the change and sign
the certification on the last page. Return the certification and all pages of the summary to
the RRB.
Employee Information

329- U - X X X X
January 2, XUX
August 2, ~ K K Y

Social Security Number
Date of Birth
Date of Death

Military Service
The employee was not in active military service after September 7, 1939.
Recent Employment
The employee worked for the following companies in the last two years:

from 05/20/1997 to 08/0112005

Star Stainless

The employee did not have self-employment earnings in any of the last three years.
Railroad Eniployment
The employee had a current connection with the railroad industry.
Employee's Family
The employee was not survived by children or grandchildre11who may be entitled to
monthly benefits.

The employee was survived by a widow(er) or surviving divorced spouse who may be
entitled to monthly benefits.
Justin Michaels
Widow(er)
329 XX-->cXX!(

-

The employee was survived by a parent who may be entitled to monthly benefits.
329 XX-XXXX
Michael Michaels
Parent

RRB Form AA-17cert

3294;

I

22000 06051 32704

Page 1

Form Approved
OMB '3;?,Zc7 - 0030

United States of America
Railroad Retirement Board

Applicant lnformation
Name and Address
Social Security Number
Daytime Telephone Number

Widow(er)'s Annuity

Type of Application Filed

You applied for this benefit based on your
relationst-ripto the employee.

You have requested that any payment due you be sent to the following bank account:

Citibank
123456789

123456789123456789

Checking

Applicant's Marriages

You were not married to anyone other than the employee.
You have not remarried since the employee's death.
Criminal Offense lnformation

Within the past 12 months you have not been imprisoned or been given a sentence of
confinement due to a conviction for a criminal offense.
Other Government Benefits

You have filed or plan to file in the next three months for Social Security benefits on your
own account.
You are not receiving a social security benefit.

In the past month you have not filed nor plan to file in the next three
nionths for Railroad
Retirement benefits on any account number.
You are not receiving a railroad retirement annuity.
You are not receiving nor do you expect to receive a pension or lump-sum payment based
on your earnings from a Federal, state or local government agency.

RRB Form AA-17cert

32948

k X 1 22000 06051 32704

Page 2

Form Approved
OMB 3Z-ZU-005 0

United States of America
Railroad Retirement Board

Earnings Information

In 2005, your earrrings were less ,than$12,000.00
In 2006, you expect your total earnings will be $15,720.00
You have not worked for a railroad or other employer in the railroad industry.
Beginning Dates and Filing Dates

You requested your annuity to begin on the earliest date permitted by law, even if you will
receive a reduced annuity.
This application will protect yol,lr filing date for Social Security benefits.

-

Application for (Application Type Certification)
0

Employee's RR Claim Number
Employee's Name
Employee's Social Security Number

A 329-. XK--Y X X K .
Elizabeth XXx>cX
329- >ex.-X X XX

Applicant's Name
Applicant's Social Security Number

Justin - XXXXX
32g-- ~ k~ K
-K X

I certify that the information I have given to the Railroad Retirement Board (RRB) in
relation to this application is true to the best of my knowledge. I know that if I make a
false or fraudulent statement in order to receive benefits from the RRB, I am committing a
crime which is punishable under Federal law.
I have received and reviewed a summary of the inforniation I provided. I understand that I
have an obligation to advise the RRB imniediately if there are any errors in the surrlmary I
received, and have made and initialed any corrections on the Summary being returned to
'.theRRB.
I have received and reviewed the booklets RB-17 SurvivorAnnuity, RB-9s Events that
Affect a Survivor Annuity and form G-77 How Earnings Affect Payment of Survivor
Annuities. I understand that I am responsible for reporting events that would affect my
annuity.

RRB Form AA-17cert

32948 *X

22000 06051 32704

Page 3

Form Approved
OMB. -3zw --60'=

United States of America
Railroad Retirement Board

I agree to immediately notify the RRB, if
I remarry;
I begin to receive a pension or receive a lump sum payment based on my earnings
from a Federal, state or local government agency;
I file for social security benefits on any person's account;
I go to work for a railroad or railroad labor organization;
My expected earnings amount changes;
My address changes;
My bank account changes;
Any person for whom I am receiving benefits dies or leaves my care;
I am confined to a jail, prison, penal institution or correctional institution due to a
conviction for a criminal offense.

Signature (First Name, Middle Initial, Last Name)

Date

(MonthIDayNear)

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

Signature o f Witness

Signature o f Witness

Address (Street, City, State and ZIP Code)

Address(Street, City, State and ZIP Code)

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1-(

Daytime Telephone N u m b e r

RRB Form AA-17cert

Daytime Telephone Number

32948 64790 22000 06051 32704

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