Application for Employee Annuity

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002
Do Not Write In This Space

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OFFICIALLY FILED
MONTH

1

DAY

/

YEAR

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OFFICE NUMBER

NEXT-TO -LAST ER

APPLICATION FOR
APPROVED

EMPLOYEE ANNUITY

1. I.

.................... ................................... .................. ............................................I , .

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DATE
- CODED
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MONTH

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DAY

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YEAR

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CODED BY
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General Instructions
Before you complete this application, be sure to read the booklet RB-1, Age and Service Employee Annuity, which explains
information you will need to answer many of the questions in this application. Also be sure to read the important notices in the
the RB-l booklet.
Type or print legibly in ink. If you need more space than is provided to answer a question, use Section 21 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

0 6 0 6 210017
Some items in this application will not apply to you and 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 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
Check the information entered by the Railroad Retirement Board (RRB) for Items 1 through 5 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.

*

Employee
identification

.

2

SOCIAL SECURITY NUMBER

3

EMPLOYEE'S NAME

4

a MAILING ADDRESS -->
CITY AND STATE

>

ZIP CODE

>

b COUNTY
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>

I RAILROAD RETIREMENT CLAIM NUMBER

>

1 5 1 DAYTIME TELEPHONE NUMBER
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>

>

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Form AA-1 (09-07) Destroy Prior Editions

Sex

1

Enter an " X in the box that shows
your sex.
Enter your name at birth if different from ltem 3.

Marital
Status

9

Current
Marriage

>

Enter your date of birth.

+

Enter an " X in the box that shows your
current marital status.

>

a Male
a Female
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Month

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Day

l

Year
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a Never Married
a Married or Separated
a Other

l

Go to ltem 16
Go to ltem 10
Go to Item 14

Enter your spouse's full name before your marriage. ----,

Previous
Marriage
History

Enter your spouse's date of birth.

+

Enter the date of your marriage.

>

Enter your spouse's social security number.
If none, enter "To Be Submitted."

*

Enter an " X in the appropriate box:
I was previously married. (Answer "No" if your only
previous marriage was an earlier marriage to your
current spouse.)
15

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Month

Year

l

Yes

>

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Day

a No

+ Go to ltem 15
+ Go to ltem 16

Give the following information for your previous marriage(s). Use Section 21 if you have more than one previous
marriage.
(i) MARRIAGE BEGAN
CITY & STATE

a

DATE

(iv) Enter your former spouse's date of birth.

b

(iii) MARRIAGE ENDED

(i i) NAME OF FORMER
SPOUSE

mDEATH DIVORCE
Q ANNULMENT
mOTHER - Explain
in
Section 21

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(v) Enter the Social Security Number of former spouse
shown in Section 15a(ii).

1

Enter your former spouse's
Place of birth

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-

Month

+
-

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Day

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Father's name

Mother's maiden name

_

Please read Part I of the RB-I booklet for an explanation of family members who could qualify you for the
Special Guaranty Computation.
Enter an " X in the appropriate box:
I have children who are unmarried and meet any of the
following conditions:
(1) Under age 18.
(2) Age 18 through 19 and attending elementary or
secondary school full-time.
(3) Age 18 or older with a continuing disability that began
before age 22 and prevents any kind of employment.

a Yes -+
a No +

Go to Note and ltem 17
Go to Item 18

Note: I f you have a child that meets the disability requirements, also complete Form AA-ISa,
Application for Determination o f Child's Disability.

Enter in each box the number
of children who meet each condition.

1 a Under age 18.
a Age
18 through 19 and attending elementary
or
secondary
school full-time.
>
a Age
18 or older with a continuing disability
that began before age 22 and prevents any
kind of employment.

Form AA-1

) Page 2

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Do not com~leteItem 18 if vou have never married; ao to Item 19.
Garnishment
or
Property
Settlement

Enter an " X in the appropriate box:
a. The RRB has been furnished with an order to enforce either
my child support or alimony obligation, or to pay part of my
present or future ra~lroadretirement benefit to a spouse or
former spouse as a part of a property settlement in a divorce
or legal separation proceeding. (NOTE: Reference to
pension rights may be found in the property settlement.)-+

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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.

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*

Enter the date of the conviction.
21

Enter the date of the sentence of confinement.

1 1
22

Enter the date that confinement began.

23

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

1 1
24

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Yes -+ Go to ltem 18b

a
a
a
a

*

b. Which situation applies?
Criminal
Offense

a
a

No

Child Support or Alimony
Property Settlement

NO

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Month

*

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-+Go to Section 4

Day

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Day

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Year

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l

Year

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Yes -+ Go to Item 24

Month

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Day

II

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Enter the date confinement ended.

Item 20

+

Month

a

-+Go to ltem 19

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Year

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lnformation About Type of Annuity
Please read Part I of the RB-1 booklet for information about age and service annuities. Also read the RB-Id booklet if you are
a ~ ~ l v i for
n a a disabilitv annuitv.

m FULL AGE ANNUITY
m FULL 60130 AGE ANNUITY
m DISABILITY ANNUITY
* m REDUCED AGE ANNUITY- LESS

Type of
Annuity

1 25 i

Enter an "Xuin the box that shows the type
-of annuity you are filing for.

THAN 30 YRS' SERVICE

Enter an " X in the appropriate box:
I am eligible for and will accept a reduced age annuity
if I am not eligible for a full age or a disability annuity. d

Section 5

Yes

cl No

lnformation About Military Service
Please read Part I of the RB-1 booklet for information about military service. Creditable military service is used to determine, in
part, your annuity eligibility. It can also be used in your annuity computation.

-

Military
Service

Enter an " X in the appropriate box:
I was in active military service, such as the Army, Navy,
Air Force or Marines, of the United States.

a
a

Yes
No

-+Go to Note and ltem 28
-+Go to Section 6

Note: I f answered "Yes," you must submit proof of your military service, such as your discharge
certificate or separation papers, as explained in the RB-1 booklet.

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

a
a
a
a

*

Enter an "X" in the appropriate box:
I had nonrailroad earnings after leaving the military service
stated in ltem 28 and before returning to the railroad. ---+
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Yes
No

-+Go to ltem 29
-+Go to ltem 30

Yes

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Form AA-1 (09-07) Page

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Military
Service
Monthly
Benefits

Enter an 'X' in the appropriate box:
I have filed, or plan to file, a claim for monthly benefits with another
federal agency based on military service performed before
January I, 1957.(Answer "No" if the other federal agency is the
Department of Veterans Affairs, the Social Security Administration,
or the Railroad Retirement Board.)

a
a

Yes
No

+ Go to ltem 31
+ Go to Section 6

*

Enter the name of the other federal agency.

-*

Enter the date you filed a claim with the agency named in Item 31 Month
and go to ltem 33.If you have not already filed a claim with that
agency, enter the date you plan to file and go to Section 6. +

Year

Day

Enter the claim number of the monthly benefit you have
already filed for.
>

Information About Your Railroad Work
Please read Part I of the RB-1 booklet to find out what railroad work is creditable. Creditable railroad work is used to
determine your annuity eligibility and is also used in the annuity computation.
Railroad
Work Before
1937

Enter an " X in the appropriate box:
I have less than 360 months of railroad work
after 1936.
Enter an " X in the appropriate box:
I worked in the railroad industry before 1937.

*

-

a
a
a
a

No

+ Go to ltem 35
+ Go to ltem 36

Yes

+ Go to Note and ltem 36

No

+ Go to ltem 36

Yes

Note: To obtain credit for your railroad service before 1937, complete and return to the RRB, Form AA-15,
Employee's Statement of Service Performed Before January 1,1937, to Employers Under the
Railroad Retirement Act.

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Last Railroad
Employment

Enter the name of the railroad company or railroad
labor organization that last employed you.

37 Enter your payroll name and identification number for
that employer.

1 38 1 Enter your last job title for that employer.

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39 Enter your last division or department and its location.
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 "TO" date.)

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-+

1 FROM
~ o n t h lDay

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1 TO
Year

l ~ o n t h Day
l

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Year

>

Enter the date you gave up or will give up your seniority
rights and all other rights to work for the employer shown
in ltem 36.(Make no entry if you have not given up your
rights because you are filing for a disability annuity.) +
Other
Railroad
Employment

Enter the name of that employer.

>

Enter your payroll name and identification number for
that employer.

*

-

Enter your last job title for that employer.

45
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a
a

Enter an " X in the appropriate box:
I worked for another employer in the railroad industry
or a railroad labor organization this year or last year. 4

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Form AA-1 (09-07) Page 4

Yes
No

+ Go to ltem 43
+ Go to ltem 49

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Other
Railroad
Employment

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

1 (cant.)

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( Day

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Year

TO
Month( Day

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Year

>

Enter the date you gave up or will give up your seniority rights
and all other rights to work for the employer shown in ltem 43.
(Make no entry if you have not given up your rights because
you are filing for a disability annuity.)
>
Railroad
Seniority
Rights

1

Enter an " X in the appropriate box:
I still have seniority or other rights to work for a
railroad employer or railroad labor organization
not listed in Item 36 or Item 43.

+

Print the name of any employer indicated
in ltem 49 with whom you still have rights
to return to work.

>

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a
a

Yes

-+ Go to Item 50

No

-+ Go to Section 7

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lnformation About Pay For Time Lost

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Please read Part II of the RB-I booklet to find out what payments can be creditable as pay for time lost.
Pay For
Time Lost

51

Enter an " X in the appropriate box:
I received or expect to receive pay for
time lost from my last railroad employer.

-

a
a

Yes -+ Go to Note and Item 52
No

-+ Go to Section 8

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Note: If answered "Yes," and you received an injury sefflemenf or elecfed fo receive "dismissal pay,"
enclose a copy of your settlemenf or election wifh your application. I f your case is sfill pending, briefly
explain if in Secfion 21.

FROM
Month1 Day

52 Enter the dates for which
these payments were made or
will be made.

+

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Year

TO
Month1 Day

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Year

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lnformation About Railroad Sick Pay

~

Please read Part II of the RB-I booklet to find out when sick payments can be creditable to Tier I.

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Railroad Sick
pay

Enter an "X" in the appropriate box:
I received or expect to receive sick pay
under a railroad wage continuation plan
(other than my own regular salary) that
was established through a company policy
or labor agreement and this pay was for a
period after the actual day I last worked.
(Answer "No" if you were carried on the
payroll and just received your regular
salary.)

a
a

Yes -+ Go to ltem 54a
No

+ Go to Section 9

>

Enter the name of the sick pay plan, if known
b

1

Enter the dates for which these payments were made or will be made for
up to 6 months after your actual day
last worked.

FROM
Month1 Day

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Year

TO
Month] Day

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Year

>
Form AA-1 (09-07) Page 5

-1

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lnformation About Your Nonrailroad Work
Please read Part IV of the RB-1 booklet, which explains how Last Pre-Retirement Nonrailroad Employment, self-employment,
and other earnings affect your annuity. Also read Part I of the booklet which explains "Current Connection."
Enter an " X in the appropriate box:
I worked for pay outside the railroad industry
either during the last 6 months I worked in the
railroad industry or after I left the railroad industry.
(Do not include self-employment. Include any
employment for an incorporated business which
you own or public service. If you are a Canadian
citizen or permanent resident, include employment
in Canada for the U.S. railroad employer performed
January 1, 1983, or later.)

1

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Most Recent
Nonrailroad

56

m Yes
m No

+ Go to Note and ltem 56
+ Go to ltem 66

>

Note: I f you had Last Pre-Retirement NonrailroadEmployment (LPE) after your annuity would begin,
complete Form G-19F, Earnings lnformation Request, only when one of the following applies:
(IThe
) annuity beginning date (ABD) is before January Iof this year or
(2) the ABD is January I, 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.

>

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

>

\ 1

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

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

Enter the name and address of your next most
recent nonrailroad employer during your last 6
months in the railroad industry or after you left
the railroad industry.

1

Enter your last job title for that employer.

62

TO
Month Day

Year

[7 I am still working

Enter an " X in the appropriate box:
The employer named in ltem 56 is either a seasonal
employer or a Federal Government agency that is
listed in Chapter 5 of the RB-1 booklet.
Recent
Nonrailroad

Year

Yes

m No

>

If none, enter "NONE" and go to Item 66

-1
>

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

II
II

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

FROM
~ o n t h lDay

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Enter an " X in the appropriate box:
The employer named in ltem 61 is either a seasonal
employer or a Federal Government agency that is
listed in Chapter 5 of the RB-1 booklet.

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Form AA-1 (09-07) Page 6

Year

TO
~ o n t h lDay

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Year

m I am still working

>

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65

I

Yes

m No

>
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SelfEmployment

If you are employed and your business is incorporated, answer ltem 66 "No." Make sure ltems 55-65 are also
completed. If your business is not incorporated, answer ltem 66 "Yes" and go to ltem 67.
Enter an " X in the appropriate box:
I was self-employed during my last
6 months in the railroad industry or
after I left the railroad industry.

0 Yes + Go to Note and Item 67
0 No + Go to Section 10

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

1
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Enter an "X" in the appropriate box:
I am still self-employed.

*

-

0 Yes + Go to Section 10
0 No + Gotoltem68

MONTH

Enter the date you were last self-employed.

68
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II

DAY

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YEAR

II

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II

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Deemed Current Connection
Please read Part I of the RB-1 booklet for an explanation of a deemed current connection.
Deemed

Enter an "X" in the appropriate box:
I have at least 25 years of railroad service
and I have indicated nonrailroad employment
in ltems 55-68 that could break my current
connection.

Current
Connection

0 Yes + Go to ltem 70
0 No + Go to Section 11

+

-

1 I
72

1

Enter an " X in the appropriate box:
I was separated from my last railroad
employer involuntarily and through no fault
of my own on or after October I,1975.

0 Yes + Go to ltem 72
0 No + Go to Item 71

Enter an " X in the appropriate box:
I was on furlough, leave of absence or
absent because of injury status with my
last railroad employer on October 1, 1975,
and was never called back to work.

0 Yes + Go to ltem 72
0 No + Go to Section 11

*

Enter an " X in the appropriate box:
I declined an offer to work in the railroad
industry in the same "class or craft" as my
last railroad job.

0 Yes

1

No

-

Go to Section 11

+ Go to Note and Section 11

ote: I f you answered either ltem 70 or ltem 71 "YesJJand ltem 72 "No," submit the required proofs
soon as possible. This will preserve your rights under the deemed current connection provisions. The
required proofs are explained in the RB-1 booklet.

Information About When Your Annuity Will Begin
Please read Part II of the RB-1 booklet for an explanation of an annuity beginning date.
Annuitv
~egining
Date

Enter an " X in the appropriate box:
I want my annuity to begin on the
earliest date permitted by law.
Enter the date you want your annuity
to begin.
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0 Yes + Go to Section 12
0 No + Go to Item 74

1 1
Month

*

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year

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Form AA-I (09-07) Page 7

Information About Your Earnings
Before answering ltems 75-87, please read Part IV of the RB-I booklet to find out how earnings can affect an age
and service annuity. For the exempt amounts, refer to Form G-77a, How Work Affects Your Railroad
Retirement Benefits.

1

If you are applying for a disability annuity but are eligible for and would accept a reduced age annuity if the disability
annuity is denied, answer ltems 75-87, which apply to the reduced age annuity. Otherwise, go to Section 13.
Earnings
Last Year
(Year)

Enter an " X in the appropriate box:
I expect my annuity to begin before
January 1 of this year.

a Yes +
a No +

Enter an " X in the appropriate box:
My total earnings from all employment last year were
more than the annual earnings exempt amount. (If all your
earnings are from only railroad employment before your
+
date last worked, answer "No.")

a Yes +
a No +

Go to ltem 76
Go to ltem 80

Go to ltem 77
Go to ltem 80

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

-

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.
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 the total amount you expect to earn this year.

Earnings
Next Year

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

(Year)

I

85

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Form AA-1 (09-07) Page 8

Go to ltem 84

a Yes +
a No +

Go to ltem 84
Go to ltem 83

*

a Yes +

Go to Item 85

D No + Go to Section 13

p

a Yes +
a

Enter an " X in the appropriate box:
I expect my total earnings from all employment next year to
be more than this year's annual earnings exempt amount. +
I

Go to ltem 81 '

*

I expect to earn more than the monthly earnings exempt
amount in employment for hire, or to perform substantial

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

Go to ltem 79

a Yes +
a No +

*

(SHOW DOLLARS ONLY)

Go to ltem 80

*

Enter an "X" in the appropriate box:
I expect my total earnings from 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.")

(Year)

a Yes +
a No +

Go to Item 86

+ Go to

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Skction 13
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Earnings
Next Year
(Cont.)

,

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

-

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.

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lnformation About Social Security Benefits
Please read Part V of the R B - I booklet to see how this application can protect your rights to social security benefits, and
to see what effect your receipt of social security benefits will have upon your railroad retirement annuity.
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.)

Social
Security
Filing Date

0 Yes
0 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.

Month

Enter the date you became, or will become, eligible
for these social security benefits.
Enter an " X in the appropriate box:
I have received my first social security
payment.

*

Enter the current total monthly amount of your
social security benefits (before reduction for
work or Medicare premiums).

*

-

94

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

95

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

Year

0 Yes -+ Go to ltem 92
0 No + Go to ltem 93

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

I

0 Yes + Go to Item 90
0 No + Go to Section 14

0 Yes + Go to ltem 94
0 No + Go to Section 14

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lnformation About Non-Covered Service Pension
Please read Part V of the R B - I booklet for information concerning non-covered service pensions. Complete Items 96 and 97
only if your date of birth is January 2, 1924, or later. Otherwise, go t o Section 15.
Non-Covered
Sewice
Pension

97

Enter an " X in the appropriate box:
I am receiving or expect to receive a pension or annuity
or lump sum in excess of contributions based on any
work after 1956 not covered by social security or
>
railroad retirement.

0 Yes + Go to ltem 97
0 No + Go to Section 15

Enter an 'X in the appropriate box:
The beginning date of the pension or
annuity is January I , 1986, or later.

0 Yes + Go to Note and Section 15
0 No + Go to Section 15

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Note: If answered "Yes," complete Form G-209, Employee Non-Covered Service Pension
Questionnaire.
Form AA-1 (09-07) Page

-1
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lnformation About Other Railroad Retirement Annuity
Please read Part V of the RB-I booklet for an explanation of the effect of your employee annuity on any other railroad
retirement annuity.
Enter an " X in the appropriate box:
I have filed within the last 30 days, or intend to file
within the next 90 days, for an annuity based on
another person's railroad earnings record. v

Railroad
Annuity

I I

Enter the full name of that other person.

99

-

-+ Go to Item 99
+= Go to Section 16

If only six numbers, enter here

Prefix

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

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a Yes
a No

*

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lnformation About Supplemental Annuity

I

Please read Part I of the RB-I booklet for an explanation of what is required to be eligible for a supplemental annuity.
Enter an " X in the appropriate box:
I am now, or will be, eligible for a supplemental annuity
from the Railroad Retirement Board (before reduction
for a company pension).

Annuity
Eligibility

Enter an "X in the appropriate box:
I am receiving, or expect to receive, a monthly
pension or lump-sum pension payment from one
or more former railroad employers.

+

a Yes
a No

-

a Yes
a No

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+= Go to ltem 102
-+ Go to Section 17

-+ Go to ltem 103
-+ Go to Section 17

103 Enter the name of the last railroad employer
with whom you still hold pension rights. P

1 0 4 Enter an 'X. in the box which most accurately
applies to the job or position which qualified
you for this pension.

a Salaried
a Non-Agreement
Agreement
+
I a Other

I
1
Month

Enter the date your pension began, or will begin, or
the date of your lump-sum pension payment.

I

106 Enter the name of the second to last railroad employer
with whom you still hold pension rights. (If this
employer is now part of the employer in ltem 103,
leave this item blank and go to ltem 109.)

-a

107 Enter an " X in the box which most accurately
applies to the job or position which qualified
you for this pension.
I

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I

Year
I

1

1

I

Salaried
Non-Agreement

1 1

Form AA-I (09-07) Page 10

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If none, enter "NONE" and go to ltem 109

Month

1

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l

a Agreement
a Other

*

108 Enter the date your second pension
began, or will begin, or the date of your
lump-sum pension payment.

109 Enter an " X in the appropriate box:
The pension named in ltem 103 or ltem 106
is based on a collective bargaining (union)
agreement.

Day

Day

Year

1
Yes

a No

*
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-1

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-I booklet for an explanation of the Medicare program.
Medicare
Enrollment

-

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

111 Enter your Medicare claim number.
(If this is a railroad retirement filing, enter the prefix. If this
is a social security filing, enter the suffix).
112 Enter an " X in the appropriate box:
I have filed for Part B within the last
>
three months.
113 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
this is a social security filing, enter the suffix.)
Date of filing

a

I

Yes
No

Year

Go to Section 18
Yes + If you are under age 65 years
and 4 months, go to Section 18.
If you are older than age 65 years and 3
months, go to ltem 115.
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 18.

No

+ Go to ltem 117
+ Gotoltemll6

Yes

+ Go to Item 118

Yes

-

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

l8

+

Month

1 17 The beginning date of my EGHP coverage is:

+ Goto Item 113
+ Gotoltem114
Day

a
a

I am currently covered by an employer group health
plan (EGHP) based on my own or my spouse's
current employment.

Item'I2

Go to Section 18

Month

+

+ Goto Item 111
+

a

116

Yes

a
a

/

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

a

I

Day

I

If applicable, the date employment will stop for the
person whose employment qualifies me for EGHP
coverage is:
118 The beginning and ending
dates of my EGHP coverage and the date last
worked in the employment
which qualified me for
EGHP coverage are:
119

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;

EGHP Ending Date

>

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

120 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.

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

--

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Year

Day

Go to ltem 119

Month

Year

Day

+

Date Employment Stopped +

b. I am requesting a Part B effective date of

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1

-

EGHP Beginning Date

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Month

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Year
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>

-t

1

a
a
a
a

Yes
NO
Yes
No

+ Go to Item 120b
+ Go to Section 18

Month

Day

I

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I

Gotoltemll9~

1
1 1 1
+ Go to Item 120
+ Go to ltem 121

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Yes

I

Year

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l

Go to
Section 18

a No
Form AA-I (09-07) Page 11

Disability Medicare
If you are filing for a disability annuity, go to Section 19.
If YOU are less than 64 years and 5 months of age, and you are nof filing for a disability annuity, you may be entitled to
Medicare benefits based on your being totally disabled for all employment and being entitled to an annuity before age 63.

1

If your entitlement begins after age 63, you may not be entitled to early Medicare, but you may be entitled to have your Tier I
benefit treated as a social security benefit for taxation purposes. See Form TB-85, lnformation About the Taxation of
Railroad Retirement Annuities, Part 6, Section 6A.
122 Enter an " X in the appropriate box:
I expect my annuity to begin before I
reach age 63.

Disability
Medicare

123 Enter an "X"in the appropriate box:
I am totally disabled for work in all
regular employment.

a
a
a
a

>

>

Yes

+ Go to ltem 123

No -+ Go to Section 19

Yes

+ Go to Note and Section 19

No

+ Go to Section I 9

I

Note: I f answered "Yes," complefe and refurn Form AA-Id, Application for Determination
of Employee's Disability, fo apply for Medicare based on disabilify.

lnformation About You If You Are Disabled
Answer Items 124-126 ONLY if you are applying for a disability annuity. Otherwise, go to Section 20. If you are applying
for a disability annuity, also complete and return Form AA-Id, Application for Determination of Employee's Disability.
You are asked about your children to determine if you are entitled to a special annuity computation.

1

Please read Part V of the RB-1 booklet for an explanation of worker's compensation benefits and public disability benefits.
124 Enter an " X in the appropriate box:
After 1950 1 had living with me at least
one of my own or my spouse's children,
who was under age 3.

Child Living
With You

125 Enter an " X in the appropriate box:
Since my disability began, I have
received, or expect to receive,
worker's compensation benefits.

I-J Yes
I-J No

>

Yes -+ Go to Note and Item 126
No

>

+ Go to Item 126

I

Note: I f answered "Yes, "proof of fhe amounf(s) and effecfive dafe(s) of your worker's
compensation benefif is required.

126 Enter an " X in the appropriate box:
Since my disability began, I have
received, or expect to receive, disability
benefits under a Federal, state, or local
government plan or law.
(Answer "No" if your benefits are social
security, veterans affairs, or welfare.)

Public
Disability
Benefits

No

+ Go to Section 20

>
I

Note: I f answered "Yes,"proof of fhe amounf(s) and effecfive dafe(s) of your public disabilify
benefif is required.
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Form AA-1 (09-07) Page 12

-1

Direct Deposit

1

Please read Part VII of the RB-1 booklet for an explanation of Direct Deposit.
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 21, or call your financial institution for the information you need to complete Items 127-131. If you do not
have a bank account, or receiving your payments by Direct Deposit would cause you a hardship go to Itern 132.
Direct
Deposit

127 Enter the name of your financial institution.
128 Enter the telephone number of your
financial institution.

Area Code

129 Enter the routing transit number of your financial institution.
130 Enter your account number. --,

Telephone Number

-

I I I I I I I

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

m Checking
m Savings
Go to Section 21

132 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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*

m
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Remarks
Remarks

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133 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.

I

I

I

Form AA-I (09-07) Page 13

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

>

a
a

YES + Go to Note and ltem 135
NO

+ Go to Item 135

Note: If answered "Yes," your guardian o r ofher representative rnusf sign fhis applicafion. Thaf
person rnusf also cornplefe and refurn Form AA-5, Application for Substitution of Payee.
I know that if I make a false or fraudulent statement in order to receive benefits from the Railroad Retirement Board
(RRB), I am committing a crime which is punishable under Federal law. Ihave received the booklets, RB-I, Age
and Service Employee 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 begin to receive a pension based on earnings that
are not covered by the Social Security Administration
(SSA) or the RRB.
IF I begin to receive benefits directly from SSA.
IF I am disabled and begin to receive worker's
compensation or public disability benefits.
IF I am entitled to a supplemental annuity from the RRB
and receive a lump-sum pension payment or begin to
receive a monthly pension from my railroad employer.
IF I am entitled to a vested dual benefit and begin to
receive a benefit based on military service performed
entirely before 1957.
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 return to work for my Last Pre-Retirement
Nonrailroad Employer and there is a change in my
estimated earnings.
IF I am filing in advance of the date(s) shown in Item(s)
40 (and 47), 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) 40 (and 47).

IF benefits I receive directly from SSA are adjusted for a
reason other than normal cost-of-living increases.
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 earn 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 my spouse who is receiving a benefit dies, or our
marriage ends in divorce or annulment.
IF a qualifying child marries or leaves my custody or
residence.
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 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 Work Affects 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.

*

SIGNATURE
(First Name, Middle Initial,

If this certification is signed by mark ("X") in ltem 135, two witnesses who know the person signing must
sign below, giving their full addresses and daytime telephone numbers.
b. Signature of Witness
a. Signature of Witness

Address (Number and Street)

Address (Number and Street)

City, State, ZIP Code

City, State, ZIP Code

Area Code

Telephone Number

I
) Page 14

Area Code

Telephone Number

I

How To Return Your Application

Before you return your application, check to make sure that:

I

*

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.

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*

You have signed and dated the application.

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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 serving your location. 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.

I

Make one final check before you seal the envelope to ensure that the following are enclosed:

I

/

*

needed proofs

*

the application form itself

*

additional forms you were asked to complete

I

Note: After the RRB receives your application, a receipt form with information about your claim
will be 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 us so
we can find out what is causing the delay.

\

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Form AA-1 (09-07) Page 15