AA-17b (10-07) Application for Determination of Widow(ers) Disability

UNITED STATES OFAMERICA
RAILROAD RETIREMENT BOARD

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

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DO NOT WRITE IN THIS SPACE
OFFICIALLY FILED
MONTH
DAY

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APPLICATION FOR
DETERMINATION
OF WIDOW(ER)'S
DISABILITY

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YEAR

OFFICE NUMBER

APPROVED

DATE CODED
MONTH

APPLICATION NUMBER

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DAY

II

YEAR

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CODED BY

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General Instructions
Before you complete this application, be sure to read Part I of booklet RE-17b, Widow(er)'s Disability Benefits, which explains information
you will need to answer many of the questions in this application.
Please read "Important Notices" on page 11 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 9 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 December 13,
1998, 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 t o do so.

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If you are completingthis 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 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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Employee
Identification

EMPLOYEE'S NAME

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EMPLOYEE'S SOCIAL SECURITY NUMBER

131
Applicant
Identification

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a

STREET ADDRESS

b

CITYAND STATE

c

ZIP CODE

d

COUNTY P

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APPLICANTS NAME

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EMPLOYEE'S RAILROAD RETIREMENT CLAIM NUMBER

4

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DAYTIME TELEPHONE NUMBER

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Form AA-17b (10-07) Destroy Prior Editions

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Information About Your Medical Condition

When
Condition
Began

8

Enter the date this condition began to adversely affect
your ability to work.

10 Enter an " X in the appropriate box:
Did your condition cause you to change:
Your job duties?
Your hours of work?
Your attendance?
Anything else about your work?

Day

Year

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Enter an " X in the appropriate box:
I have worked since the date in ltem 8.

How
Condition
Affects
Work

Month

es

Q No

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+ Go to Item 10

+

Go to ltem 12

Yes

No

Q If "Yes" to
a n y item, go
to item 11

8

Q If "No" to

tl

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8

a l l items, go
to Item 12

11 Explain what the changes in your work circumstances were, the dates they occurred, and why your condition
made these changes necessary.
Changes in Work Circumstances

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Dates

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Why Your Condition Made Changes Necessary

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When
Unable to
Work

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Year
Month Day -

12 Enter the date you could no longer work because of your
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condition.
13 Describe how your condition affects you and keeps you from working.

Current
Work
Status

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14 Enter an " X in the appropriate box:
My condition prevents me from working now.

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Yes

Q No

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+

Go tosection 4
Go to ltem 15

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15 Enter the date you became able to work again.

lnformation About Your Medical Care

.

Medical
16
Care or
Examination

Enter an " X in the appropriate box:
Yes
I have received medical care or been examined for my
condition since the date in ltem 8. P Q No

Treatment or 17
Testing

Enter an " X in the appropriate box:
I have been treated or tested (inpatient or outpatient) at a
hospital, institution or clinic, including a Department of
Veterans Affairs or other government facility.

Form AA-17b (10-07)

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Page 2

+ Go to Item 17

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Go tosection 5

Yes + Go to Item 18

Q No

+ Go to Item 19

Treatment or 18 Enter information about each hospital, institution, or clinic where you have received treatment or care
Testing
since the date in Item 8.
(Continued)

a

Name of Facility

Address and ZIP Code

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Attending Physician's Name
Enter an " X in the appropriate box:
Outpatient
lnpatient
Patient Number

m

m

Dates Treated or Tested

Telephone Number

Area Code

f Describe Type of Treatment or Testing
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Name of Facility

Address and ZIP Code

Attending Physician's Name

I Enter an " X in the appropriate box:
lnpatient

m

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Outpatient
Area Code

Patient Number

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Dates Treated or Tested

II

Telephone Number
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Describe Type of Treatment or Testing
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Name of Facility

Address and ZIP Code

Attending Physician's Name

1

Enter an " X in the appropriate
box:
. .
.
lnpatient
Outpatient
Patient Number

m

Dates Treated or Tested

m

Area Code

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Telephone Number
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f Describe Type of Treatment or Testing
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Doctor
Treatment

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19 Enter an " X in the appropriate box:
My personal physician or other doctor treated me since
the date in Item 8.
Page 3

+

m Yes
m No

--

Go t o ltem 20
Go to ltem 21
Form AA-17b (10-07)

Doctor
Treatment
(Continued)

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20 Enter information about each personal physician or other doctor who has treated you.
a

Name of Physician

Address and ZIP Code

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Area Code

Patient Number

1 Dates Treated or Examined

b

II

Telephone Number
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! Describe Type of Treatment or Testing

Name of Physician

Address and ZIP Code

Patient Number
Dates Treated or Examined

! Describe Type of Treatment or Testing
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m Yes
m No

Enter an " X in the appropriate box:
A medical doctor restricted my daily
activities since the date in ltem 8.

Activity
Restriction

22

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Go t o ltem 22
Go t o ltem 26

Enter the name of the medical doctor
who imposed the restriction.

Describe the restriction.

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Form AA-17b (10-07)

Page 4

Activity
25 Enter the address of the
Restriction
medical doctor in ltem 22,
(Continued)
if it has not previously been
printed in Items 18 or 20. -+

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Medication

Enter an " X in the appropriate box:
Medication has been prescribed for me.

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m Yes
m No

--

Go to Item 27
Go to Section 5

Enter the name or type of medication and the dosage from the prescription label.
Enter information for all medications prescribed for you.
NAMETTYPE:

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DOSAGE:(grams, number of pills,etc.)

I FREQUENCY:

Information About Your Education and Training
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Enter the highest grade of school you completed
and the last year you attended school.

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m Yes

Enter an " X in the appropriate box:
I attended technical school.
Describe the type of technical school you attended.

31

Enter an "X in the appropriate box:
I received a certification or license from
the technical school I attended.

32

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m Yes
m No
m Yes
m No
m Yes
m No

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Enter an " X in the appropriate box:
The certification or license I received is
currentlv in effect.

>

Enter an " X in the appropriate box:
I have received specialized training.

>

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Go t o Item 30
Go t o Item 33

Go t o Item 32
Go t o ltem 33
Go t o Item 33
Go t o ltem 33
Go t o Item 34
Go t o Section 6

Enter the type of specialized training you received and the period of time you received it.

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TYPE

DATES

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Enter an " X in the appropriate box:
Have you used any of this training in your work?

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m Yes
m IVo

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Go t o Item 36
Go t o Section 6

Describe when and how you use(d) this training in your work.

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Page 5

Form AA-17b (10-07)

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Information About Your Daily Activities
Activities

37 After each activity listed below, check the one box that best describes your ability to do that activity.
EASY - I can easily do the activity.
HARD - I can do the activity with difficulty or with help.
NOTATALL - I cannot do the activity even with help.
ACTIVITY

I EASY I HARD I {ok, I

Sitting

a

Standing

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EXPLANATION - Explain each "HARD answer.

tl+
tl+

m +
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Walking
Eating
Bathing
Dressing (Tying Shoes,
Combing Hair, Etc.)
Other Bodily Needs
Indoor Chores (Meal
Preparation, Laundry,
Cleaning, Etc.)
Outdoor Chores (Shopping,
Yardwork. Etc.)
Driving a Motor Vehicle
Using Public Transportation
Conducting Personal
Business (Talking to and
Dealing with Other People)
Reading English (For
example, newspapers
and magazines)
Writing English (For example,
notes and letters)

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Enter any additional information that describes your daily activities.

Work
Activities

39 Enter an 'X" in the appropriate box:
Have you ever been employed
or self-employed?

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0 Yes
Go to Note and Item 40
0 No + Go to Section 8

Note: If you answered "Yes" and you are a widow(er) filing for a disability annuity,
also complete and return to the RRB Form 6-251, Vocational Report.
Form AA-17b (10-07)

Page 6

Work for an

Enter an " X in the appropriate box:
I have worked for pay for an employer in the last
12 months. (Do not include any self-employment.)

Employer
Last
12 Months

-

a Yes

-+

Go t o ltem 41

No -+ Go t o Item 43
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Enter your earnings, before any deduction, for each month you have already worked this year. Then, starting with
the current month, enter your expected gross earnings for this month and each remaining month this year.
JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

JULY

AUGUST

SEPTEMBER

OCTOBER

NOVEMBER

DECEMBER

I Enter your earnings, before any deduction, for each month last year.

SelfEmployment

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

JULY

AUGUST

SEPTEMBER

OCTOBER

NOVEMBER

DECEMBER

Enter an " X in the appropriate box:
Have you been self-employed in the last 12 months? +

Last
12 Months

---+ Go t o ltem 44
No -+ Go t o ltem 46

Enter your net earnings for each month you have already worked this year. Then, starting with the current month,
enter your expected earnings for this month and each remaining month this year.

45

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

JULY

AUGUST

SEPTEMBER

OCTOBER

NOVEMBER

DECEMBER

1 Enter your net earnings. before any deduction, for each month last year.
JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

JULY

AUGUST

SEPTEMBER

OCTOBER

NOVEMBER

DECEMBER

Enter an " X in the appropriate box:
Do you expect to work during the next 12 months?
(Include self-employment, if any.)

Work Next
12 Months

a Yes
NO

>

-+ Go t o Item 47

-+ Go t o Section 8

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47

Enter the name and address of the
person or company for whom you
expect to work. (If self-employed,
>
enter "Self.")
Enter the date@)you expect
to work. (For example, "June
and July," "Indefinitely Starting
9-96," etc.)

>

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Enter the gross amount you expect
to earn. (If you are self-employed,
enter the net amount.)

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Page 7

Form AA-17b (10-07)

General Information
Filing AA-17
or AA-18

50

Social
Benefits

Public
Service
Pension

Enter an 'X" in the appropriate box:
I am filing either Form AA-I7 or Form AA-I8 at
this time.

>

Enter an 'X' in the appropriate box:
I have filed, or expect to file, for monthly social
security disabilitv benefits?

>

Enter the social security claim number
under which vou have filed or will file.

>

------

a Yes + Go to ltem 56
a No
Go to ltem 51
a Yes Go to ltem 52
a No
Go to ltem 53

Enter an "X in the appropriate box:
I am receiving or expect to receive a pension or I have received
or expect to receive a lump-sum payment instead of a pension
based on my earnings from an agency of the Federal, state, or
local government. (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.)

a Yes
a No
a Yes
a No

I amlwas an employee of the Federal Government.

Go to ltem 54
Go to ltem 56

Go to Note and ltem 56
Go to ltem 55

Note: I f answered 'Yes," also complete and return the RRB Form G-208, Public
Service Pension Questionnaire, and verification of your pension.

a Yes
a No

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.

to Item 56

Go to Note and Item 56

Note: I f answered "No," also complete and return the RRB Form 6-208, Public
Service Pension Questionnaire, and verification of your pension.
Criminal
Offense

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56

1 1
57

58

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

>

Enter the date of the sentence of confinement.

1 1
60

Enter the date that confinement began.

61

Enter an " X in the appropriate box:
Is your disability related to your confinement?
Enter an " X in the appropriate box:
Has the confinement ended?

63

a Yes
a No
Month

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Day

Go to Section 9

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a >

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Page 8

Year

Month

1

IayYear

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Day

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Year

Yes
No

Yes

Go to Item 63

No

Go to Section 9

>

Enter the date confinement ended.

-arm AA-17b (10-07)

Go to Item 57

a Yes
a No

Enter an "X in the appropriate box:
Is your disability related to the commission of the
criminal offense? w

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59

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Month

Day

Year

Remarks

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 space to enter
any additional information that you feel may be important to include.

Page 9

Form AA-17b (1 0-07

1 Certification
Cehlication

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

Q Yes

+

Q No

--

Go to Note and ltem 66
Go to Item 66

Note: I f answered "Yes," your guardian or other representative must sign
this application. That person must also complete and return Form AA-5,
Application for Substitution of Payee.

I know that if I make a false or fraudulent statement in order to receive benefits from the RRB, or if I fail to disclose earnings or report employment of any kind to the RRB, I am committing a crime which is punishable
under Federal law.

I have received the booklet RB-17b, Widow(er)'s Disability Benefits. I understand that I am responsible for
reporting any events that would affect my annuity, as explained in that booklet.
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 perform work for any employer, railroad or nonrailroad, or perform any self-employment work;
If my condition improves;
If I am confined in a jail, prison, penal institution, or correctional facility due to a conviction for a criminal offense.
If my address changes;
If l remarry;
If I file for social security benefits based on any person's earnings record;
If I begin to receive a pension from an agency of the Federal, state, or local government or
if my present payments change.
I know that if I am receiving a disability annuity and fail to report work and earnings promptly, I am committing a
crime punishable by Federal law and may result in criminal prosecution and/or penalty deductions in my annuity payments.
Signature
(First Name, Middle Initial,
Last Name)

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Month

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Day

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Date

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Year

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If this certification is signed by mark ('X') in ltem 66, two witnesses who know the person signing must sign
below, giving their full addresses and daytime telephone numbers.
a Signature of Witness

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

Telephone Number

Area Code

Telephone Number

>

Daytime Telephone Number
b Signature of Witness

Address (Number and Street)

1

City, State, and ZIP Code

>

Daytime Telephone Number
Form AA-li

Page 10

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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 12 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

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Note: Make no entries on page 12, which is the receipt for your claim. After the RRB receives your application,
they will complete the blanks on the receipt and send if 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.

PAPERWORK REDUCTIONACT AND PRIVACY ACT NOTICES
The information asked for in this form is needed to determine your entitlement to benefits under the Railroad
RetirementAct. The RRB's authority for requesting this information is Section 7(b)(6) of the Railroad Retirement Act.
We estimate that this form takes and average of 40 to 50 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 the completion time, to Chief of lnformation Resources Management,
Railroad Retirement Board, 844 North Rush Street, Chicago, IL 60611-2092.

COMPUTER MATCHING AND PRIVACY PROTECTION ACT NOTICE
The Computer Matching and Privacy Protection Act of 1988 requires the RRB to advise you that information you
have provided may be used, without your consent, in automated matching programs. These matching programs are
a computer comparison of RRB records with records kept by other Federal, state, or local governmental agencies.
lnformation from these matching programs can be used to establish or verify a person's eligibility for federally funded
or administered benefit programs and for repayment of payments or delinquent debts under these programs.

Page 11

Form AA-17b (10-07

EMPLOYEE'S NAME

APPLICANT'S NAME

RAILROAD RETIREMENT BOARD CLAIM NUMBER

DATE CLAIM RECEIVED

Your application for railroad retirement disability benefits has been received and will be processed as quickly as possible. If
you change your address, or if there is some other change that may affect your claim, you or your representative should
report the change. The changes to be reported are listed below. Always give us your claim number when writiqg or calliqg
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 9:00AM to 3:30PM,
Monday through Friday.

a

Address - If your address changes.
Work - If I perform work for any employer, railroad or nonrailroad, or perform any self-employment work.

a

Remarriage - If you remarry.

a

Condition - If your condition improves.

a

Social Security - If you file for benefits on any person's earnings.
Criminal Offense - If you are confined in a jail, prison, penal institution, or correctional facility due to a conviction
for a criminal offense.
Public Service Pension - If you begin to receive a pension from an agency of the Federal, state, or local
government or if your present payments change.

When a change occurs after you are entitled to disability benefits, you should report the change at once. You or your
representative can make the reports by telephone, mail, or in person, whichever you prefer.

To report any of the above changes, contact:

Tf Telephone Number:

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

b

'orm AA-17b (1 0-07)

U S RAILROAD RETIREMENT BOARD
844 N RUSH ST
CHICAGO IL 60611-2092
Page 12