AA-19a (10-07) Application for Determination of Child's Disability

Application for Survivor Insurance Annuities

Form AA-19a (10-07)

Application for Survivor Insurance Annuities

OMB: 3220-0030

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 3220-0030 can be found here:

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UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

FORMAPPROVED
O.M.B. NO. 3220-0030
DO NOT WRITE IN THIS SPACE

OFFICIALLY FILED
MONTH

APPLICATION FOR
DETERMINATION OF
CHILD'S DISABILITY

DAY

OFFICE NUMBER

YEAR

APPROVED

(

DATE CODED

APPLICATION NUMBER

MONTH

DAY

YEAR

[

l
l
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1
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1
CODED BY

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General Instructions
Before you complete this application, be sure to read Part Iof booklet RB-19a, Child's Disability Benefits, which explains
information you will need to answer many of the questions in this application.
Please read "Important Notices" on page 13 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
February 12, 2000, as:

Some items in this application will not apply to you so you will not need to answer them. Based on your answer to a
question, you may be told to skip to another item number, or even another section. Follow the instructions that tell you to
"Go to" another item. These are designed to save you time and help you move through the application form quickly, filling
in only necessary information. If no "Go to" instructions are given, answer the next item in order. Do not skip any
items unless directed to do so.

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

Identifying Information
Check the information entered by Railroad Retirement Board (RRB) for Items 1 through 9 for accuracy.
b If the information is correct, go to Section 3.
b If the information is not correct, cross out the incorrect information and enter the correct information above it.
b If the information is missing,
- fill it in.
Employee

identification 1

EMPLOYEE'S NAME

EMPLOYEE'S SOCIAL SECURITY NUMBER

EMPLOYEE'S RAILROAD RETIREMENT CLAIM NUMBER

I I

Applicant
4
Identification

-I
I

ZIP CODE

d COUNTY

1 6 1 DAYTIME TELEPHONE NUMBER
I

1 7 1 CHILD'S SOCIAL SECURITY NUMBER

CHILD'S NAME

5 a STREET ADDRESS

(

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I

I
-

-----C

CHILD'S DATEOFBIRTH

u FEMALE
CHILD'S GENDER s
iJ MALE
L
Form AA-19a (10-07) Destroy Prior Editions

-1

Information About The Child's Medical Condition

Month

1 Began

p r
1
Condition
Became
Severe
How
Condition
Affects

Current
Work
Status

12 Enter the date this condition began to severely interfere with the child's
activities.
Enter an " X in the appropriate box:
Has this condition kept the child from working?

-a

Describe how this condition has kept the child from working.

Enter an " X in the appropriate box:
Does this condition prevent the child
from working now?

Year

Day

I
I

Month

Day

Year

Yes + Go to Item I 4
No --+ Go to Item I 5

a Yes + Go to ltem 17
+

0No

--+

Go to ltem I 6

Month

16 Enter the date this condition no longer
prevented work.

-1

Year

Day

Information About The Child's Medical Care
Enter an "X" in the appropriate box:
Has the child received any medical care, or been examined
>
for this condition since the date in Item 12?

Examination
Medical
Care
Before 22

11 Enter the date this condition began to affect the child.

Enter information about each doctor or medical facility from whom the child received treatment
or care before age 22.
a NAME OF FACILITY

1 /

--+Go to Item 18
C3, No + Go to Section 5
Yes

ADDRESS AND ZIP CODE

ATTENDING PHYSICIAN'S NAME

Enter an 'X" in the appropriate box:

INPATIENT

OUTPATIENT

[]
Area Code

PATIENT NUMBER

Telephone Number

I
DATES TREATED
OR TESTED

Form AA-I 9a (10-07)

DESCRIBE TYPE OF TREATMENT OR TESTING

Page 2

Medical
Care
Before 22
(Cont.)

18 b

NAME OF FACILITY

ADDRESS AND ZIP CODE

ATTENDING PHYSICIAN'S NAME

Enter an "X" in the appropriate box:
INPATIENT
OUTPATIENT

CI
Area Code

PATIENT NUMBER

Telephone Number

NAME OF FACILITY

ADDRESS AND ZIP CODE

ATTENDING PHYSICIAN'S NAME

Enter an "X" in the appropriate box:
INPAI-IENT
OUTPA-I-IENT

5
AreaCode

PATIENT NUMBER

DATES TREATED
OR TESTED

DESCRIBE TYPE OF TREATMENT OR TESTING

Note: If the child received more medical care before age 22, use Section 9
to discuss additional treatment or care. Include the dates for each period of care.
Other
Medical

Enter information about any other doctor or medical facility from whom the child has received treatment or
care since the date in Item 12.

ADDRESS AND ZIP CODE

ATTENDING PHYSICIAN'S NAME

Enter an " X in the appropriate box:
OUTPATIENT
INPATIENT

CI
.Area Code

PATIENT NUMBER

DATES TREATED

Telephone Number
I

DESCRIBE TYPE OF TREATMENT OR TESTING

Page 3

Form AA-1 Sa (10-07)

Other
Medical
Care
(Cont.)

19 b NAME OF FACILITY

ADDRESS AND ZIP CODE

ATTENDING PHYSICIAN'S NAME

Enter an 'X" in the appropriate box:
INPATIENT Q
OUTPATIENT

C]I

Area Code

PATIENT NUMBER

Telephone Number
I

OR TESTED

Note: If the child received more medical care, use Section 9 to discuss
additional treatment or care. Include the dates for each period of care.
Activity
Restriction

Enter an " X in the appropriate box:
A medical doctor restricted the child's daily
activities since the date in Item 12.
who imposed the restriction.

Q Yes -+ Go t o ltem 21
Q No --t Go t o ltem 25

Medication

Enter the date the restriction began.

Describe the restriction.

Enter the address of the
medical doctor in ltem 21,
if it has not previously been
printed in Items 18 or 19. +

Enter an " X in the appropriate box:
Medication has been prescribed for the child?

- Q Yes

Form AA-19a (10-07)

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

Page 4

Go t o Item 26
Go t o Section 5

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

Month

FREQUENCY:

Year
I

Information About The Child's Daily Activities
Daily
Activities

Enter an "X"in the appropriate box:
Does the child attend a health or
socialization center daily?

C]Yes

--+ GOto Item 28

Q No

--t

Go to Item 29

NAME OF FACILITY

daytime telephone number of
the center.

STREET ADDRESS
CITY AND STATE

ZIP CODE
Area Code

Telephone Number

29 After each activity listed below, check the one box that best describes the child's ability to do that activity.
EASY - The child can easily do the activity.
HARD -The child can do the activity with difficulty or with help.
NOTAT ALL - The child cannot do the activity even with help.
ACTIVITY
Sitting
Standing
Walking

EASY HARD

EXPLANATION - Explain each "HARD" answer.

~ , ~ , a , +
CI a C I +
CI

Eating

Bathing

C]I

CI-+

rZ]I

Dressing (Tying Shoes,
Combing Hair, Etc.)

a +
CI]I+

a +

CS-,

01
Cl
0

Conducting Personal
Business (Talking to and
Dealing with Other People)

0 +
0,-

CI-t

Reading English (For
example, newspapers
and magazines)

CI-,

Writing English (For example,
notes and letters)

a a a +

Other Bodily Needs
Indoor Chores (Meal
Preparation, Laundry,
Cleaning, Etc.)
Outdoor Chores (Shopping,
Yardwork, Etc.)
Driving a Motor Vehicle
Using Public Transportation

1 30 /

,';'::,

Describe the child's participation in social activities, hobbies, and home or family activities, including chores,

Information About The Child's Education And Training
Schooling
and
Training

First
School
Attended

33 Enter the name and address

Enter an " X in the appropriate box:
Has the child ever attended any type of school or
received some type of special training?

Yes
>

-4

Go to ltem 33

Q No -+ Go to Section 7

NAME

of the first school the child
+
attended.

STREET ADDRESS
CITY AND STATE

ZIP CODE

34 Describe the type of school or training.

36
School
Attended

I /

Enter the dates the child attended school or training.
If the child is still in attendance at this school,
draw a line in the "To" boxes.
Enter the highest level the child achieved.
Enter the name and address
of the second school the
child attended. If none, enter
"NONE" and go to ltem 45.

/ I

______)

From
~onth

To
Year

[

Month

Year

Month

-------------+

STREETADDRESS

CITY AND STATE

ZIP CODE
I

38 Describe the type of school or training.

From

39 Enter the dates the child attended school or training.
If the child is still in attendance at this school,
draw a line in the "To" boxes.

MonUl

40 Enter the highest level the child achieved. ----------?,
Form AA-19a (10-07)

Page 6

To
Year

Third
School

Attended

1 41 1

I I

Enter the name and address of the third
school the child attended. If none, enter
"NONE" and go t o ltem 45.

I I

SCHOOL'S NAME
STREETADDRESS

ZIP CODE

Describe the type of school or training.

Enter the dates the child attended school or training.
If the child is still in attendance at this school, draw a
line in the "To" boxes.

I Enter the highest level the child achieved.

From

Note: If the child attended more than three schools, complete
ltem 45 and use Section 9 to discuss the other schools.
Problems
in School

Describe any special problems or difficulties the child had in school.

Information About The Child's Work Activities
Any Work

Most
Recent
Job

Enter an " X in the appropriate box:
Has the child everworked?
Enter the title of the child's most
recent job.

48 a Enter the employer's name and address.
b Describe the type of business.

+ Go t o Item 47
Go to Section 8

+
--,

I 1
49

a Yes
a No

EMPLOYER'S NAME
STREETADDRESS
CITYAND STATE

Enter the dates the child worked at this job.
If the child is still working at this job, draw a line
in the "To" boxes.

From

Enter the number of hours worked each week.

Describe the child's basic duties and responsibilitiesfor the job. Include any difficulties the child had or
has performing the full range of duties.

Enter an " X in the appropriate box:
Did the child's duties differ from those of other
workers with the same job title?
Page 7

a Yes
+

+ Go to ltem 53
No -aGo t o Item 54
Form AA-19a (10-07

Describe how the child's duties differed from those of other workers with the same job title.

Recent
Job

Describe the amount of supervision and assistance the child received.

Explain why the child stopped working at this job. If the child is still working, go t o ltem 56.

Second
Most
Recent
Job

Enter the title of the child's second most recent job.
If none, enter "NONEWandgo to Item 65.

EMPLOYER'S NAME
STREET ADDRESS

I
c Is this a sheltered employment?
Q Yes
Q No

CITY AND STATE
ZIP CODE

Enter the dates the child worked at
this job.
Enter the number of hours worked each week.

r:onth

ear

~onm

Describe the child's basic duties and responsibilities for the job. Include any difficulties the child had or
has performing the full range of duties.

Enter an "X" in the appropriate box:
Did the child's duties differ from those of other
workers with the same job title?

u Yes

+ Go t o Item 62

Q No

+ Go to ltem 63

Describe how the child's duties differed from those of other workers with the same job title.

Describe the amount of supervision and assistance the child received.

=arm AA-19a (10-07)

Page 8

year

Second
Vlost
iecent
lob
Cont.)

Explain why the child stopped working at this job.

Note: If the child had more than two jobs, use Section 9 to discuss the otherjobs.
Work for
jn
imployer
.ast 12
donths

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

Q Yes --+ Go to Item 66
Q No 4 Go to Item 68
>

Enter the child's earnings, before any deduction, for each month the child has already worked this year.
Then, starting with the current month, enter the child's expected gross earnifisfor that month and each
remaining month this year.
JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

JULY

AUGUST

SEPTEMBER

OCTOBER

NOVEMBER

DECEMBER

Enter the child's earnings, before any deduction, for each month last year.

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE
1

JULY

;elflmployment
.ast 12
donths

AUGUST

SEPTEMBER

Enter an " X in the appropriate box:
Has the child been self-employed in the last 12 months?

OCTOBER

NOVEMBER

DECEMBER

Q Yes + Go to ltem 69
No

+ Go to ltem 71

Enter the child's earnings, before any deduction, this month and for each month the child worked this year.
Then, starting with the current month, enter the child's expected earnings for that month and each remaining
month this year.
JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

JULY

AUGUST

SEPTEMBER

OCTOBER

NOVEMBER

DECEMBER

Enter the child's earnings, before any deduction, for each month last year.

ilork Next
2 Months

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

JULY

AUGUST

SEPTEMBER

OCTOBER

NOVEMBER

DECEMBER

Enter an " X in the appropriate box:
Does the child expect to work during the next 12 months?
(Include self-employment, if any.)
Page 9

Q Yes + Go to Item 72
Q No -+ Go to Section 8
Form AA-19a (10-07

Work Next
12 Months
(Cont.)

Enter the name and address of the person or
company for whom the child expects to work.
(If self-employed, enter "Self.")
73 Enter the dates the child expects to work.
(For example, "June and July," "Indefinitely
Starting 12-98," etc.)
74 Enter the gross amount the child expects
to earn. (If self-employed, enter the net
amount.)

General Information
Enter an " X in the appropriate box:
Are you filing Form AA-3, Form AA-18, or
Form AA-19. at this time?
Guardianship 76

>
+
-

- - -

Q Yes -aGo to Item 89
Q No

Q Yes + Go to Item 77

Enter an " X in the appropriate box:
Has the court appointed a legal guardian for the child?

Enter an " X in the appropriate box:
Are you the court appointed guardian for the child?
Enter the name, address, and
daytime telephone number of
>
the guardian.

NAME

Q No

Go to ltem 78

Telephone Number

STREET ADDRESS
ClTY AND STATE

Area Code

Enter an X" in the appropriate box:
Is the child currently in your care?

Q No

Go to Item 80

ClTY AND STATE
I

Child's
Marital
Status

I
I

I
>

Q No
>

83 Enter the date the child married.

No
I

85 Enter the date the child's marriage ended.

Social
Security
Benefits

88
Criminal
Offense

Go to Item 87

Month

Day

Year

Go to Item 85

Month

Day

Year

Q Yes

Enter an " X in the appropriate box:
Was the child's marriage annulled?

Enter an " X in the appropriate box:
Have you filed, or do you expect to file, for monthly
social security disability benefits or SSI for the child?

Enter the social security claim number and suffix under
which you have filed or will file.

Enter an " X in the appropriate box:
Within the last 12 months, has the child been imprisoned or given a
sentence of confinement due to a conviction for a criminal offense?

Form AA-I9a (10-07)

Telephone Number

Q Yes + Go to Item 87

Enter an " X in the appropriate box:
Is the child still married?

Q Yes + Go to Item 83

Enter an " X in the appropriate box:
Has the child married?

STREET ADDRESS

Enter the guardian's relationship
to the child.

+ GO to Hem P

Area Code

yes

NAME

ZIP CODE

- --

Enter the name, address, and
daytime telephone number of
the guardian.

Go to Item 79

Q Yes + Go to Item 79

ZIP CODE

1 79 1

Go to ltem 76

Page 10

Q No
Q Yes -aGo to Item 88
Q No

+ Go to ltem 89
Suffix

Q Yes + Go to ltem 90

Go to Item 98

Enter an "X" in the appropriate box:
Is the child's disability related to the commission of the criminal offense?

Yes

92 Enter the date of the sentence of confinement.

93 Enter the date that confinement began.

tl No
Month
Month
I

Enter an " X in the appropriate box:
During the confinement, is the child participating in a rehabilitation
program which is expected to result in the ability to engage in gainful
work within a reasonable time after release?
Enter an 'X' in the appropriate box:

Has the confinement ended?

97 Enter the date confinement ended.

Day

Year

Day
I

Year

Yes

Enter an " X in the appropriate box:
Is the child's disability related to the confinement?

tl No
Yes

a Yes

tl No
+ Go to Item 97

-aGo to Section 9
Month I
Day
I
>
I

Year

Remarks
Remarks

98 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 11

Form AA-I9a (10-07)

Certification
Certification

Enter an "X* in the appropriate box:
A guardian or other representative will sign this
application on behalf of the child applicant.

a Yes
a No

Go t o Note and Item 100
Go t o ltern 99

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

I 1

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-I9a, Child'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 the child performs work for any employer, railroad or nonrailroad, or performs any selfemployment work.
If the child reported estimated earnings and the amount changes;
If the child's condition improves and a doctor advises the child is able to work;
If the child dies;
If the child marries;
If an application is filed for social security benefits for the child based on any person's earnings records;
If the child's address changes;
If I am receiving payments on behalf of the child and the child leaves my care;
If the child is confined in a jail, prison, penal institution, or correctional facility due to a conviction for a
criminal offense.
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)
Date

Month I

Day

Year

*u
I

If this certification is signed by mark ("X) in Item 100, 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

1 1

I I

Daytime Telephone Number (include area code)

Area Code

Telephone Number

Area Code

Telephone Number

b Signature of Witness

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

I I

Daytime Telephone Number (include area code)

'orm AA-19a (10-07)

Page 12

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 14 of this
application. No matter which envelope you use, you must put the correct postage on the envelope. Be careful to provide enough postage, because your application and the accompanying forms may weigh more than a standard letter.
The U.S. Postal Service will not deliver your application unless it has the correct postage.
Make one final check before you seal the envelope to ensure that the following are enclosed:

*
*
*
/

NEEDED PROOFS
THE APPLICATION FORM ITSELF
ADDITIONAL FORMS YOU WERE ASKED TO COMPLETE

Note: Make no entries on page 14, which is the receipt for your claim. After the RRB receives your application,
they will complete the blanks on the receipt and send it back to you. When it is returned to you, you will know
that the RRB has received your application and has started the work needed to determine if you are entitled to
benefits. If you do not receive the receipt within two weeks aRer you filed this application, please contact us so
we can find out what is causing the delay

PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICES
The information asked for in this form is needed to determine your entitlement to benefits under the Railroad
Retirement Act. The RRB's authority for requesting this information is Section 7(b)(6) of the Railroad RetirementAct.
We estimate this form takes an average of 45 to 65 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.

COIWPUTER 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 13

Form AA-19a (10-07

1 Employee's Name
Applicant's Name

Railroad Retirement Board Claim Number

Date Claim Received

Your application for a railroad retirement child's disability annuity 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 writing or calling about your claim. If you have any questions about your claim, we will be glad to help
you. If you need to personally visit one of our field offices, please call for an appointment. You will not be refused
service if you do not have an appointment, but our staff can serve you better when an appointment is made. Most
offices are open to the public from 9:00 AM to 3:30 PM, Monday through Friday.

Work-If the child performs work for any employer,
railroad or nonrailroad, or performs any selfemployment work.

Marriage--If the child marries.
Social Security-If an application is filed for
social security benefits for the child based on
any person's earnings record.

Earnings-If the child reported estimated earnings
and the amount changes.

Address-If

Improvement i n the Child's Condition-If the child's
condition improves
and a doctor advises the child is
able to work.

the child's address changes.

Child in Your Car€!--lf YOU receive payment On behalf
of the child, and the child leaves your care.
Criminal Offense-If the child is confined in a jail,
prison, penal institution, or correctional facility due to a
conviction for a criminal offense.

Death-If the child dies.

When a change occurs after the child becomes entitled to a disability annuity, it should be reported 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:

Telephone Number:

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

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

Form AA-19a (10-07)

Page I 4

File Type	application/pdf
File Modified	2009-07-15
File Created	2009-07-15