AA-17cert (09-06) Application Summary and Certification

United States of America
Railroad Retirement Board

CURRENT (COMPLETED)

Form Approved
OMB 3220-0030

APPLICATION SUMMARY and CERTIFICATION
Employee’s Name
RR Claim No.

Elizabeth Michaels
A 929-48-7489

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

929-48-7489
January 2, 1940
August 2, 2005

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

from 05/20/1997 to 08/01/2005

The employee did not have self-employment earnings in any of the last three years.
Railroad Employment
The employee had a current connection with the railroad industry.
Employee’s Family
The employee was not survived by a children or grandchildren who may be entitled to
monthly benefits.
The employee was survived by a widow(er) or surviving divorced spouse who may be
entitled to monthly benefits.
Justin Michaels
Widow(er)
929-48-8479
The employee was survived by a parent who may be entitled to monthly benefits.
Michael Michaels
Parent
123-45-6789

RRB Form AA-17cert (09-06)

20121 02614 38360 29294 8748

Page 1

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0030

Applicant Information
Name and Address
Social Security Number
Daytime Telephone Number

Justin Michaels
929-48-8479
312-555-1212

Type of Application Filed

Widow(er)’s Annuity

You applied for this benefit based on your relationship to the employee.
You have requested that any payment due you be sent to the following bank account:
Citibank
123456789
123456789123456789
Checking
Applicant’s Marriages
You were not married to anyone other than the employee.
You have not remarried since the employee’s death.
Criminal Offense Information
Within the past 12 months you have not been imprisoned or been given a sentence of
confinement due to a conviction for a criminal offense.
Other Government Benefits
You have filed or plan to file in the next three months for Social Security benefits on your
own account.
You are not receiving a social security benefit.
In the past month you have not filed nor plan to file in the next three months for Railroad
Retirement benefits on any account number.
You are not receiving a railroad retirement annuity.
You are not receiving nor do you expect to receive a pension or lump-sum payment based
on your earnings from a Federal, state or local government agency.
RRB Form AA-17cert (09-06)

20121 02614 38360 29294 8748

Page 2

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0030

Earnings Information
In 2005, your total earnings were less than $12,000.00.
In 2006, you expect your total earnings will be $15,720.00.
You have not worked for a railroad or other railroad employer in the railroad industry.
Beginning Dates and Filing Dates
You have requested your annuity begin on the earliest date permitted by law, even if you
will receive a reduced annuity.
This application will protect your filing date for Social Security benefits.
Application for a Widow(er)’s Annuity - Certification
Employee’s RR Claim Number
Employee’s Name
Employee’s Social Security Number

A 929-48-7489
Elizabeth Michaels
929-48-7489

Applicant’s Name
Applicant’s Social Security Number

Justin Michaels
929-48-8479

I certify that the information I have given to the Railroad Retirement Board (RRB) in
relation to this application is true to the best of my knowledge. I know that if I make a
false or fraudulent statement in order to receive benefits from the RRB, I am committing a
crime which is punishable under Federal law.
I have received and reviewed a summary of the information I provided. I understand that I
have an obligation to advise the RRB immediately if there are any errors in the summary I
received, and have made and initialed any corrections on the Summary being returned to
the RRB.
I have received and reviewed the booklets RB-17, Survivor Annuities, RB-9s, Events that
Affect a Survivor Annuity, and form G-77, How Earnings Affect Payment of Survivor
Annuities. I understand that I am responsible for reporting events that would affect my
annuity.
RRB Form AA-17cert (09-06)

20121 02614 38360 29294 8748

Page 3

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0030

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

_________________________________
Signature (First Name, Middle Initial, Last Name)

___________________
Date (Month/Day/Year)

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

__________________________________
Signature of Witness

_______________________________
Signature of Witness

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

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

(_____)____________________________
Daytime Telephone Number

(_____)________________________
Daytime Telephone Number

RRB Form AA-17cert (09-06)

20121 02614 38360 29294 8748

Page 4