Form AA-3 Application for Spouse/Divorced Spouse Annuity

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

FORM APPROVED
OMB NO. 3220-0042

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DO NOT WRITE IN THIS SPACE
OFFICIALLY FILED
MONTH
DAY

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APPLICATION FOR
SPOUSEIDIVORCED
SPOUSE ANNUITY

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OFFICE NUMBER

YEAR

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APPROVED

/

APPLICATION NUMBER

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DATE CODED
MONTH
DAY

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1

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YEAR

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CODED BY

Before you complete this application, be sure to read the booklet RB-30, Spouse/Divorced Spouse Annuity, which explains information
you will need to answer many of the questions in this application. Also be sure to read the important notices at the end of the booklet
RB-30.
Type or print legibly in ink. If you need more space than is provided to answer a question, use Section 15 for this purpose. If you do not
know the answer to a question, print "Unknown" in the space provided for the answer.
When entering dates, always use numbers. Also, be sure there is one number in each box. For example, you would enter June 6, 2007, as:
Month

Day

Year

016 016 2 0 1 0 7
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 i n order. Do not skip any items unless directed to do so.

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

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Check the information entered by the Railroad Retirement Board (RRB) for Items 1 through 6 for accuracy.
If the information is correct, g o t o 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.

identifying Information

Employee
Identification

AppllCant
Identification

1

EMPLOYEE'S RAILROAD RETIREMENT CLAIM NUMBER

2

EMPLOYEE'S SOCIAL SECURITY NUMBER

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3

EMPLOYEE'S NAME A

4

APPLICANT'S NAME

5

a

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6

>

COUNTY

->

DAYTIME TELEPHONE NUMBER
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*

MAILING ADDRESS ->

ZIP CODE
b

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Form AA-3 (03-07) Destroy Prior Editions

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Information About You And Your Family
Social
Security
Information

Enter your social security number.

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Go to
ltem 8

To be submitted + Go to ltem 10

+

If none, enter an "X" by "To be submitted."

-

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Enter an " X in the appropriate box:
My name appears on my social security card
exactly as it does in Item 4.
Enter your name as it appears on your
social securitv card.
Sex

Birthdate

Yes +Go to ltem 10

*1

Enter an " X in the box that shows your sex.

11 Enter your date of birth.

*

Birth

12 Enter your name at birth if
different from Item 4.

*

Current
Marriage

13 Enter the date of your marriage

Marital
Status

14 Enter an " X in the appropriate box:
Marital status to the railroad employee.

Name At

Previous
Marriage

to the railroad employee.

Marrlage
H~story

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MALE
FEMALE
Month

Day

Year

Month

Day

Year

*

-

MARRIED

+

Go to Item 15

DIVORCED

+

GO to Item 17

Enter an " X in the appropriate box:
The railroad employee was married
before our marriase.
16 Enter an " X in the appropriate box:
I was married before my marriage
to the railroad employee.

Subsequent
Marriage

NO + GO to ltem 9

+

yes + GO to ltem 18
NO + Go to ltem 19

+

17 Enter an " X in the appropriate box:
I was married after my marriage
to the railroad employee.

Yes

*

No

18 If you are a spouse, enter the following information about your marriage before your marriage to the employee.
If you are a divorced spouse, enter the following information about your marriage afteryour marriage to the
employee. If applicable, enter information for more than one marriage in Section 15.
Marriage Ended

Marriage Began

a

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2. City and State

6. City and State

3. Former Spouse's Name

7. Reason

4. Former Spouse's Social Security Number

*1

Death

1Divorce

Other - Explain in Section 15

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I Enter vour former spouse's
(1) ~ a i of
e birth

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F o r m AA-3 (03-07)

Month

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Day

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Complete 18b if you do not know your former spouse's social security number.
b

Annulment

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Year
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(2) Place of birth

*

(3) Father's name

+-

(4) Mother's maiden name

+
Page 2

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Criminal
Offense

19 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.

Yes
No

*

--

Go to Item 20
Go to Section 4

-

*

20 Enter the date of the conviction.

1 21 1 Enter the date of the sentence of

Month

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Day

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-

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Year

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confinement. I

22 Enter the date that confinement began.

Month

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

Yes
NO

Month

*

24 Enter the date confinement ended.

Year

Day

--

Go to Item 24
Go to Section 4

Day

Year

Information About Type Of Annuity
Please read Parts I & Ill of the RE-30 booklet for information about spouse and divorced spouse annuities and reductions for
early retirement.
FULL AGE ANNI-IITY

rn ANNUITY
BASED ON
CHILDREN
Enter an " X in the box that shows the type of
spouse annuity you are filing for.

DIVORCED SPOUSE
WITH PREVIOUS
AGE REDUCTION

1

1

}

::Jon

6

yes

rn No

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Information About Children In Your Care
Please read Part I of the RE-30 booklet for an explanation of "child-in-care."
Enter an " X in the appropriate box:
I have one or more of the railroad employee's
children in my care who are unmarried and under
age 18. (This includes natural children, adopted
children, stepchildren and dependent
grandchildren.)

Care

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::126

REDUCEDAGE
ANNUITY

*

Enter an " X in the appropriate box:
I will accept a reduced age annuity if
I am not eligible for a full age annuity
or an annuity based on child(ren).

}

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Yes

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Page 3

NO

--

Go to ltem 28
GO to ltem 33
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Form AA-3 (03-07)

Children

Children
Not Living
With
Applicant

Print the requested information for every child in your care who would count toward qualifying you for an annuity.
Print the youngest child in 28, the second youngest in 29, and so on. If a child does not have a social security
number, enter "TO BE SLIBMITTED."
Enter an "X" in the
Relationship to Employee
Child's Full Name and
appropriate box:
(Check
One)
Social Security Number
Date of Birth
The child is disabled
28c
Natural
128d I
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28e
Day
Year
E l Yes
Month

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33 Print the requested information for every child not living with you. Print the youngest child in (a).
Explain your parental responsibilities in Section 15.

Full Name
Of Child

Person With Whom Child Now Lives
Child's Address

Name

a

(

Note: Items 34-45 are reserved.

)

Information About Your Railroad Work
Please read Part II of the RB-30 booklet for an explanation of work that you must stop.
Railroad
Work

-

46 Enter an " X in the appropriate box:
I have worked for a railroad or other employer in the
railroad industrv or a railroad labor oraanization.

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Last
47 Enter the name of the railroad company or railroad
Railroad
labor organization that last employed you.
Employment
48 Enter your payroll name and identification
number for that employer. (If you did not
work for the employer named in Item 47 this
year or last year, leave this item blank.)
49 Enter your last job title for that employer.

I I (If you did not work for the employer named
I I in Item 47 this year or last year, leave this
I item blank.)
Form AA-3 (03-07)

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Page 4

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Yes + Go to Item 47
No + Go to Section 7

Relationship
To Child

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zioad

Employment

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50 Enter your last division or department
and its location for that employer.

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Enter the dates you worked for that employer.
(If your railroad employment has not ended,
enter the last date you will work for that
employer in the " T O date.)

FROM
Month

Enter an " X in the appropriate box:
I relinquish my seniority rights and all other
rights to work for the employer shown in ltem 47
as of the last date entered in Item 51.
Other
Railroad

No

>

Enter the name of that employer.

>

Enter your payroll name and Identification
number for that employer.

w

Enter your last job title for
that employer.

>

Enter your last division or department
and its location for that employer.

>

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Dav

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Enter an "X" in the appropriate box:
I relinquish my seniority rights and all other
rights to work for the employer shown in
ltem 54 as of the last date entered in ltem 58.

Enter an " X in the appropriate box:
I still have seniority rights or other rights to return
to work for a railroad employer or a railroad labor
organization not listed in Items 47 or 54.
Enter the name and address of any additional
employer indicated in ltem 60 with whom you
still have rights to return to work.

Yes + Go to Item 54
No

+ Go to Item 60

FROM

-

Enter the dates you worked for the employer
named in ltem 54. (lf your railroad em~10vment Month
has not ended, enter the last date you wiil work
for this employer in the " T O date.)
I

Year

Day

yes

-

56

Month

Year

Day

Enter an "X in the appropriate box:
I have worked for another railroad or other
employer in the railroad industry or a railroad
labor organization this year or last year.

Work

Railroad
Seniority
Rights

TO

TO

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Month

Year

1

1

1

1

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Dav

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Year

1

1

1

yes
No

Yes

+ Go to Item 61

No + Go to Section 7

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Note: Your spouse annuify cannof begin unfil you relinquish your righfs fo employmenf
wifh the employer(s) named in Items 47-61.

Page 5

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Form AA-3 (03-07)

lnformation About Your Nonrailroad Work
Do not complete this section if you are filing for a divorced spouse annuity.
Please read Part IV of the RB-30 booklet for information about nonrailroad work and how employment affects your
annuity.

Nonrailroad
Work

Enter an " X in the appropriate box:
I worked for pay outside the railroad industry within the 6
months before the date I expect my annuity to begin. (Do
not include self-employment. Include any employment for
an incorporated business which you own or public service.)

i

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Yes

+ Go to Note and ltem 63

NO

+ Go to Item 73

Note: I f you had Last Pre-Retirement NonrailroadEmployment (LPE) after your annuity would begin,
complete Form G-196 Earnings lnformation Request, only when one of the following applies:
(1) The annuity beginning date (ABD) is before January 1 of this year or
(2) the ABD is January 1, or later, of this year, and you ceased working in LPE after the ABD month.

Enter the name and address of your current or most
recent nonrailroad employer.

Most Recent
Nonrailroad
Work

64

Enter your current or most recent job title
for that employer.

65

Enter your average monthly salary for that employer.
(SHOW DOLLARS ONLY)

>

Enter the dates you worked for that
employer. (If you have not set the date
you expect to stop working, leave the
"TO" date blank and check the box
"I am stdl working.")

FROM
Month

-rn

Enter an " X in the appropriate box:
The employer named in ltem 63 is a seasonal employer.
Next Most
Recent
Nonrailroad
Work

1 68 1
1

69

+

TO
Day

Year

Month

Day

I am still working

Yes

rn

If none, enter "NONE" and go to Item 73

Enter the name and address of your next most
recent nonrailroad employer within the 6 months
before the date you expect your annuity to begin.

I

Enter your last job title for that employer.
Enter your average monthly salary for that employer.
[SHOW DOLLARS ONLY)
Enter the dates you worked for that
employer. (If you have not set the date
you expect to stop working, leave the
"TO" date blank and check the box
"I am still working.")

Month

*

Enter an " X in the appropriate box:
The employer named in ltem 68 is a seasonal employer. --,
SelfEmployment

Da

I am still working
yes

I f you are employed and your business is incorporated, answer Item 73 "No." Make sure Items 62-72 are also
completed. I f your business is not incorporated, answer ltem 73 "Yes" and go to ltem 74.

1

Enter an "X" in the appropriate box:
I was self-employed during the last
6 months.

+

Yes

-+Go to ltem 74

No

-+ Go to Section

8

Note: I f answered 'Yes," complete and retum Form AA-4, Self-Employment and Substantial Service
Questionnaire, to the RRB.

Form AA-3 (0

-07)

Year

Page 6

Yes

Enter an "X" in the appropriate box:
I am still self-employed.

NO
Month

75 Enter the date you were last
self-employed.

I

+ Go to Section 8
+ GO to ltem 75
Year

Day

-

w

lnformation About When Your Annuity Will Begin
Please read Part II of the RE-30 booklet to find out when your annuity can begin.
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Annuity
Beginning

76 Enter an " X in the appropriate box:
I want my annuity to begin on the
earliest date permitted by law.

Date

Yes

77 Enter the date you want your annuity to begin.

r
1

+

J 'E
Month

NO

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+ Go to Section 9
+ GO to item 77

Day

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Year

lnformation About Your Earnings

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Before answering Items 78-90, please read Part IV of the R E 3 0 booklet to find out how earnings can affect your annuity.
For the exempt amounts, refer to Form G-77a, How Work Affects Your Railroad Retirement Benefits.

Earnings
Last
Year

78 Enter an "X" in the appropriate box:
I expect my annuity to begin before
Januarv 1 of this vear.
79 Enter an "X" in the appropriate box:
My total earnings from all employment
last year were more than the annual
earnings exempt amount.

>

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

>

1 81

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.

Earnings
(Year)

I

+ Go to Item 80

No

+ Go to ltem 83

Yes

+ Go to Item 83
+ Go to Item 82

$

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No

-m m m m
-

84 Enter the total amount you expect
to earn this year.
(SHOW DOLLARS ONLY)
I

Yes

>

O

83 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. (If
all your earnings are from only railroad employment
before your date last worked, answer "No.")

This Year

NO + Go to Item 83

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82 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.

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Yes + Go to ltem 79

--

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A

N

m

Yes

+ Go to Item 84

No

+ Go to ltem 87

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Page 7

Form AA-3 (03-07)

Earnings
This Year
(Cont.)

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.

b

Enter an " X next to each month this year in which
you did not, or do not expect to, earn the monthly
earnings exempt amount or perform substantial
services in self-employment.

*

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

Earnings
Next Year
(Year)

Yes + Go to ltem 87
NO + Go to ltem 86

-

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

*

Yes + Go to ltem 88
No + Go to Section 10

Yes + Go to ltem 89
No + Go to Section 10

-

Enter an " X next to each of the first four
months of next year in which you expect
to earn less than this year's monthly
earnings exempt amount.

Information About Social Security Benefits
Please read Part V of the RB-30 booklet to see how this application can protect your rights to social security benefits, and
to see what effect social security benefits will have upon your railroad retirement annuity.
Social
Security
Filing Date

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

Yes
No

*

-

Enter an " X in the appropriate box:
I have filed, or plan to file within the next 90 days,
an application for social security benefits.

Social
Security
Benefits
I

93 Enter the date you became or will become
eligible for these social security benefits.

Yes + Go to ltem 93
NO + Go to Section 11
Month

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94 Enter an " X in the appropriate box:
I have received my first social security payment.

95 Enter the current total monthly amount of
your social security benefits (before
reduction for work or Medicare premiums).
Form AA-3 (03-07)

Page 8

Year

l

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Yes + Go to Item 95
No + Go to ltem 96

$

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Social
Security

Enter an "X" in the appropriate box:
All or part of my social security benefits
described above are based on the earnings
of someone other than the railroad
employee or myself.

Benefits
(Cont.)

Yes
No

+ GO to item 97
+ Go to Section 11

>

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Enter the social security number of the person on whose
earnings your social security benefits are based.
Enter the name of the person on whose earnings
your social security benefits are based.

98
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lnformation About Other Railroad Retirement Annuity

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Please read Part V of the RB-30 booklet for an explanation of the reduction for other railroad retirement annuities.
Mher
Railroad
Annuity

1 1I
99

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Enter an "X. in the appropriate box:
previously filed, or I gm now filing for a
separate railroad retirement annuity based
on an earnings record of someone other than
the railroad employee named in ltem 3.
(Include yourself if applicable.)

II

100 Print the full name of that other person.

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

I

Yes
No

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+ Go to ltem 100
+ Go to Section 12

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Prefix

1

If only six numbers,
enter here:

+

lnformation About Public Service Pension
Please read Part V of the RB-30 booklet for an explanation of the reduction for a Public Service Pension.
Public
Service
Pension

102 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 a agency of the Federal, state,
or local government. (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.)

1

103 Enter an "X" in the appropriate box:
I amlwas an employee of the Federal Government.

Yes

+ Go to ltem 103

No

+ Go to Section 13

Yes

+ Go to Note and Section 13
+ Go to ltem 104

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No

Note: If answered "Yes," complete and return to the RRB, Form G-208, Public
Service Pension Questionnaire, and verification o f your pension.

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Page 9

Form AA-3 (03-07)

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.

Public
Service
Pension
(Cont.)

1

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-

Yes + Go to Section 13
No + Go to Note and Section 13

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

Information About Medicare
Complete this section only if you are 64 years and 5 months of age or older.

Please read Part VI of the RB-30 booklet for an explanation of the Medicare program.
Medicare
Enrollment

105 Enter an "X" in the appropriate box:
I have a Medicare card that shows entitlement
to Medicare medical insurance (Part B).

Yes + Go to ltern 106
No + Go to ltem 107

*

-

106 Enter your Medicare claim number.
(If this is a railroad retirement filing, enter the prefix.
If it is a social security filing, enter the suffix.)

107 Enter an " X in the appropriate box:
I have filed for Part B within
the last three months.

Prefix

Suffix

Go to Section 14

Yes + Go to ltern 108a

*

-

108 a Enter the social security number or railroad retirement claim number under which you filed. (If this
is a railroad retirement filing, enter the prefix. If it
is a social security filing, enter the suffix.)
b Enter the date you filed.

No
Prefix

Suffix

Month

Enter an " X in the appropriate box:

Go to
Section 14

Yes + If you are under age 65 years
and 4 months, go to Section 14.
If you are olderthan age 65 years and 3
months, go to ltem 110.
No + I understand that I elected not to
enroll in Part B and that the premium rate
may be higher if I do enroll later in Part B.
Go to Section 14.

110 Enter an " X in the appropriate box:
I am currently covered by an employer group health
plan (EGHP) based on my own or my spouse's
current employment.

Yes -+Go to ltern 112
No + G o t o l t e m l l l

*

-1

111 Enter an " X in the appropriate box:
I was previously covered by an EGHP based on my
own or my spouse's current employment.

Yes -+Go to ltem 113
No + Go to Section 14

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EGHP coverage is:

If applicable, the date employment will stop for the
person whose employment qualifies me for EGHP
coverage is:
Form AA-3 (03-07)

Year

Day

F

I wish to enroll in Part B.

/I121 The beginning date

+ Go to Item 109

Page 10

Month

Day

Day

I

Year

Year

GOto Item II d

Medicare

113 The beginning and ending dates of my EGHP
coverage and the date last worked in the employment
which qualified me for EGHP coverage are:

(Cont.)

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EGHP Beginning Date
EGHP Ending Date
Date Employment Stopped

Go to ltem 114

-I

Enter an " X in the appropriate box:
I wish to enroll in a special enrollment period.

Yes + Go to Item 115a
No + Gotoltem 116

115 Enter an " X in the appropriate box:
a. I am enrolling in Part B while either still covered by
an EGHP or during the first full month after my
EGHP coverage.
>
b. I am requesting a Part B effective date of

No + Go to Section 14

----+

116 Enter an " X in the appropriate box:
I am requesting premium surcharge relief
for the months of EGHP coverage.

I

Yes + Go to Item 115b

Month

Day

I

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Year

1

I

Go to
Section 14

I

yes
No

>

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Direct Deposit

-

Please read Part VII of the RB-30 booklet for an explanation of Direct Deposit.

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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 15, or call your financial institution for the information you need to complete Items 117-121, below.
lf you do not have a bank account, or if you believe receiving your payments by Direct Deposit would cause you a
hardship, go to ltem 122.
~
i
Deposit

1
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~ 117~ Enter
~ the
t name of your financial institution.

I

118 Enter the telephone number of your
financial institution.

>

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119 Enter the routing transit number of your financial institution.

120 Enter your account number.

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Area Code

-*

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Telephone Number
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+

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

-

Checking
Savings
Go to Section 15

122 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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Page II

Form AA-3 (03-07)

Remarks
Remarks

123 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.

Form AA-3 (03-07)

Page I 2

Certification

1

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Certification

I

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

/

YES + Go to Note and Item 125
NO

+ Go to Item I25

Note: If answered "Yes," your guardian or other representative must sign this application. That

\ person must also complete and return FormAA-5, Application for Substitution of Payee.

\

I know that if I make a false or fraudulent statement in order to receive benefk from the Railroad Retirement Board
(RRB), I am committing a crime which is punishable under Federal law. I have received the booklets, RB-30,
Spouse/Divorced Spouse Annuity and RB-9, Employee and Spouse Annuities-Events That Must Be
Reported. I understand that I am responsible for reporting events that would affect my annuity as explained in these
booklets. I certify that the information I gave the RRB on this application is true to the best of my knowledge.
I agree.to immediately notify the RRB:
IF I go to work for a railroad or railroad labor
organization, or return to work in any capacity in the
railroad industry.
IF I am filing in advance of the date(s) shown in
Item(s) 51 (and 58), and there is a change in a date.
IF I receive a settlement with credit for railroad
service as "pay-for-time-lost" for months after the
date(s) shown-in Item(s) 51 (and 58).
IF I return to work for my Last Pre-Retirement
Nonrailroad Employer and there is a change in
my estimated earnings.
IF I begin to receive benefits directly from the Social
Security Administration.
IF benefits I receive directly from SSA are adjusted for
a reason other than normal cost-of-living increases.

,

.
.

IF I remany (if I am filing for a divorced spouse annuity).
IF a qualifying child marries or leaves my custody or
residence.
IF my address changes,
IF I am confined in a jail, prison, penal institution, or correctional facility due to a conviction for a criminal offense.
IF I eam more than the annual earnings exempt amount.
IF I perform work, including self-employment, for a
family owned, controlled or managed business,
including a business operated, managed or owned
by me, a family member, friend or close associate,
whether for pay or not, and without regard to how
the business is organized (e.g., sole proprietorship,
partnership, corporation, LLC, etc.).
IF I become a corporate officer of, own, or operate a
corporation (including a corporation owned by a
family member or friend) whether for pay or not.

IF I begin to receive a public service pension or there is
a change in the amount of my public service pension.
IF my marriage ends in death or divorce (if I am
filing for a spouse annuity).

IF I receive anything of value in lieu of salary or
wages for any work that I performed.

Also, if I am covered by the earnings restriction provisions of the Railroad Retirement Act, I have received and
reviewed Form G-77a, How WorkAffects Your Railroad Retirement Benefits. Failure to report any of the
above events or other events that may affect my annuity may result in a penalty deduction from my annuity;
criminal andlor civil prosecution.

1
-

SIGNATURE
(First Name, Middle Initial,
Last Name)
DATE

1
**

Month

I

Day

I

Year

1
1

126 If this certification is signed by mark ( " X ) in ltem 125, two witnesses who know the person signing must
sign below, giving their full addresses and daytime telephone numbers.

'

City, State, ZIP Code

Area Code

Telephone Number

Page 13

Area Code

Telephone Number

Form AA-3 (03-07)

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:

*

NEEDED PROOFS

*

THE APPLICKI-ION FORM ITSELF

*

ADDITIOIVAL FORMS YOU WERE ASKED TO COMPLETE

/ Note: After the RRB receives your application, a receipt form with information about your claim \
will b e sent to you. When you receive it, 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 have filed this application, please contact u s so
w e can find out what is causing the delay.

orm AA-3 (03-07)

Page 14