3220-0030

OMB NO. 3220-0030

Justification

Application for RRB Survivor Insurance Annuities

RRB Forms AA-17, AA-17b, AA-17cert, AA-17sum,

AA-18, AA-19, AA-19a, and AA-20

1. Circumstances of information collection - Under Section 2(d) of the Railroad Retirement Act (RRA), annuities are payable to surviving widow(er)s, children, and certain other dependents. Lump-sum benefits are payable after the death of a railroad employee only if there are no qualified survivors of the employee immediately eligible for annuities. With the exception of a lump-sum residual death benefit, eligibility for survivor benefits depends on whether or not the employee was "insured" under the RRA at the time of death.

To be insured under the RRA, an employee must have at least 10 years of railroad service, or 5 years of railroad service after 1995, and a "current connection" with the railroad industry at the time of retirement or death. To meet the current connection requirement, an employee must generally have worked for a railroad in at least 12 of the months in the 2-1/2 years before retirement. If the employee died before retirement, railroad service in at least 12 of the months in the 2-1/2 years before death will meet the current connection requirement for the purpose of paying survivor benefits.

If a deceased employee was not insured, jurisdiction of any survivor benefits payable is transferred to the Social Security Administration (SSA), and survivor benefits are paid by that agency instead of the RRB. Regardless of which agency has jurisdiction, the deceased employee's railroad retirement and social security credits are both used for the purpose of benefit computations.

Types of Survivor Benefits

Annuities are payable to widow(er)s and unmarried children. In certain cases, benefits are payable to dependent parents, remarried widow(er)s, grandchildren, and surviving divorced spouses.

Widow(er)s' annuities are payable at:

 Age 60 - Age reductions are applied if the annuity begins before the widow(er) attains retirement age.

 Ages 50-59 - The widow(er) must be permanently and totally disabled and unable to work in any regular employment. The disability must have begun within 7 years after the employee's death or within 7 years after the termination of an annuity based on caring for a child of the deceased employee. A 5-month waiting period is required after the onset of disability before a disability annuity can begin.

 Any age - If the widow(er) is caring for a child of the deceased employee who is under age 18 or a disabled child of any age who became disabled before age 22.

Survivor annuities may be payable to:

 A parent at age 60 who depended on the employee for at least half support. If the employee is also survived by a widow(er) or child who can qualify for an annuity, the parent's annuity is limited to the amount that social security would pay (Tier I only).

 A remarried widow(er) or a surviving divorced spouse. Benefits are limited to the amount social security would pay (Tier I only).

The widow(er) must have remarried after age 60 (age 50-59 if disabled and entitled to a disability annuity prior to the remarriage). If the remarriage occurred prior to age 60, the remarriage must have ended. The widow(er) must also have attained age 60 or be between the ages 50-59 and totally disabled; or be under age 60 and have an employee’s child in his or her care and custody who is under age 16 or over age 16 and disabled.

 A surviving divorced spouse married to the employee for at least 10 years, who is unmarried (or remarried under the conditions described above) and has attained age 60, or is age 50-59 and is totally disabled. A surviving divorced spouse can qualify at any age if caring for an employee’s child who is under age 16 or is over age 16 and disabled. In this type of case, the 10-year marriage requirement does not apply.

The portion of a survivor annuity equivalent to a social security benefit may continue to be paid to a widow(er), remarried widow(er), or surviving divorced spouse who remarries after age 60, or to a disabled widow(er), remarried disabled widow(er) or disabled surviving spouse who remarries after age 50. Benefits may also continue for a young widow(er) if caring for an employee’s child who is under age 16 or disabled, provided that the remarriage is to a person receiving railroad retirement or social security benefits.

Other survivor annuities are payable to:

 a child under age 18;

 a child age 18-19 in full-time attendance at an elementary or secondary school, payable until the earlier of the date the student graduates from high school or the end of the school term 2 months after the student attains age 19;

 a disabled child over age 18 if the child became totally and permanently disabled before age 22;

 a dependent grandchild meeting any of the requirements described above for a child, if both the grandchild's natural parents are deceased or disabled; and

 a stepchild or adopted child of the employee meeting any of the requirements described above for a child, if the employee was contributing at least one-half of the money and goods needed for that child's support at the time the employee died or, when applicable, at the beginning date of the employee's period of disability.

The requirements for the benefits are prescribed in 20 CFR 216, 217, 218 and 219.

2. Purposes of collecting/consequences of not collecting the information - The RRB utilizes the following manual and electronic forms to obtain information needed to determine entitlement to, and the amount of, various survivor annuities.

Manual Forms

Form AA-17, Application for Widow(er)'s Annuity, which is used when the applicant is a widow(er) or a surviving divorced spouse filing on the basis of age or disability, obtains information about the applicant’s marital history, work history, benefits from other governmental agencies, railroad pensions and Medicare entitlement. An applicant filing on the basis of disability also completes Form AA-17b, Application for Determination of Widow(er)’s Disability, as a supplement to the AA-17. An applicant filing on the basis of having the employee’s child in their care should use Form AA-18, Application for Mother's/Father's and Child's Annuity, rather than Form AA-17.

Manual Form AA-17 is designed for self-administration and is completed by an applicant or by a representative on behalf of an applicant. Items 1-6 are pre-filled by the RRB with identifying information before the form is mailed to the applicant for completion.

After the application is completed, the applicant must read, sign, and date the application’s Certification page, which carries the required fraud language and lists events that could affect their annuity and must be reported to the RRB.

The completed application(s) is returned to the field office in the pre-addressed return envelope included for that purpose. After the application is entered into the APPLE system, Form AA-17rec, Receipt for Claim, is generated and provided to the applicant. This receipt advises that processing of the application has begun and provide a general description of the application process; a reminder of events that could affect the annuity and must be reported to the RRB; and RRB telephone numbers to report any events or changes.

The RRB proposes the following changes to Form AA-17.

• Delete the instructions before current item 60, which state to only answers items 60 and 61 if the application is being filed in September, October, November or December. The information is no longer needed.

• Due to the Department of Treasury’s initiative to discontinue issuing paper checks, and to offer alternative payment methods,

  • Modify the title of Section 8 from “Direct Deposit” to “Receiving Your Payments.”

  • Rewrite the introduction below the Section 8 title to include a reference to the Direct Express® Debit MasterCard®, as a new option.

  • Create new item 77 to request the applicant choose a method of payment; “Direct Deposit,” “Direct Express® card,” or “Neither” if they must continue to receive a paper check for the time being.

  • Renumber current Direct Deposit items from 77-81 to 78-82.

  • Delete current item 82. Hardship information will no longer be secured by the RRB.

• Other minor editorial changes.

Form AA-17b, Application for Determination of Widow(er)s Disability, which is used as a supplement to Forms AA-17 or AA-18 when a widow(er) or surviving divorced spouse is filing for an annuity or Medicare benefits on the basis of disability, obtains information about the applicant’s medical condition, medical care, education, training, and work activity.

A disability annuity may be payable if the widow(er) or surviving spouse is unable to work in any regular employment because of permanent disability. Field office personnel use the information from Section 4 of the AA-17b to initiate requests for medical evidence used in disability determinations. The evidence is secured by Forms G-250, Medical Assessment, G‑250a, Medical Assessment of Residual Functional Capacity, and RL‑11b, Disclosure of Hospital Medical Records (OMB 3220‑0038). If the AA-17 or AA-17b shows the applicant has filed for benefits at SSA, the RRB asks SSA for any medical evidence they have developed before initiating our own request.

Form AA-17b is designed for self-administration. Items 1-6 are pre-filled by the RRB with identifying information before the form is mailed to the applicant for completion. The Paperwork Reduction Act and Privacy Act Notices are found on the form.

After the application is completed, the applicant must read, sign, and date the application’s Certification page, which carries the required fraud language and lists events that could affect their annuity and must be reported to the RRB.

The completed application is then returned to the field office in the pre-addressed return envelope included for that purpose. After the application is released, a Receipt for Claim is provided to the applicant. This receipt advises that processing of the application has begun and provide a general description of the application process; a reminder of events that could affect the annuity and must be reported to the RRB; and RRB telephone numbers to report any events or changes.

The RRB proposes no changes to Form AA-17b.

Form AA-18, Application For Mother's/Father's and Child's Annuity, is completed by an applicant who is a widow(er) or surviving divorced spouse caring for an employee’s child who is either under age 18 or became disabled before age 22. The form, which serves as an application for both applicant and child benefits, obtains information about the applicant’s marital history, children, work history, and benefits from other governmental agencies.

Manual Form AA-18 is designed for self-administration by the applicant. Items 1-6 are pre-filled by the RRB with identifying information before the form is mailed to the applicant for completion.

After the application is completed, the applicant must read, sign, and date the application’s Certification page, which carries the required fraud language and lists events that could affect their annuity and must be reported to the RRB.

The completed application is then returned to the field office in the pre-addressed return envelope included for that purpose and entered into the APPLE system. After the application is released, Form AA-17rec, Receipt for Claim, is generated and provided to the applicant. This receipt advises that processing of the application has begun and provide a general description of the application process; a reminder of events that could affect the annuity and must be reported to the RRB; and RRB telephone numbers to report any events or changes.

The RRB proposes the following changes to Form AA-18.

• Delete current item 67, which asks if the application is being returned in September, October, November or December. The information is no longer needed.

• Due to the Department of Treasury’s initiative to discontinue issuing paper checks, and to offer alternative payment methods,

  • Modify the title of Section 9 from “Direct Deposit” to “Receiving Your Payments.”

  • Rewrite the introduction below the Section 9 title to include a reference to the Direct Express® Debit MasterCard®, as a new option.

  • Create new item 72 to request the applicant choose a method of payment; Direct Deposit, Direct Express® Debit MasterCard®, or Neither if they must continue to receive a paper check for the time being.

  • Delete current item 78. Hardship information will no longer be secured by RRB.

• Renumber items.

• Other minor editorial changes.

Form AA-19, Application for Child's Annuity, is completed on behalf of a minor or disabled child when there is no widow(er) applying for benefits or the widow(er) applying is not related to the child and is not the guardian. Monthly benefits may be payable to a minor child under age 18, a disabled child over age 18 (if the child became permanently disabled before age 22), or a child age 18-19 who is in full-time attendance at an elementary or secondary school. Form AA-19 obtains information about the child’s work history and benefits from other governmental agencies. One application is completed for all children belonging to the same guardian.

An application on behalf of a disabled child is accompanied by Form AA-19a, Application for Determination of Child's Disability. An application on behalf of a child who is age 18-19 and in full-time attendance at an elementary or secondary school at the time of the employee's death is accompanied by Form G-315, Student Questionnaire (OMB 3220-0123), which obtains information about the student’s school attendance, work, and marital status.

Manual Form AA-19 is designed for self-administration. Items 1-6 are pre-filled by the RRB with identifying information before the form is mailed to the applicant for completion.

After the application is completed, the applicant must read, sign, and date the application’s Certification page, which carries the required fraud language and lists events that could affect their annuity and must be reported to the RRB.

The completed application(s) is then returned to the field office in the pre-addressed return envelope included for that purpose and entered into the APPLE system. After the application is released, Form AA-17rec, Receipt for Claim, is generated and provided to the applicant. This receipt advises that processing of the application has begun and provide a general description of the application process; a reminder of events that could affect the annuity and must be reported to the RRB; and RRB telephone numbers to report any events or changes.

The RRB proposes the following changes to Form AA-19.

• Delete current item 57, which asks if the application is being returned in September, October, November or December. The information is no longer needed.

• Due to the Department of Treasury’s initiative to discontinue issuing paper checks, and to offer alternative payment methods,

  • Modify the title of Section 9 from “Direct Deposit” to “Receiving Your Payments.”

  • Rewrite the introduction below the Section 9 title to include a reference to the Direct Express® Debit MasterCard®, as a new option.

  • Create new item 62 to request the applicant choose a method of payment; Direct Deposit, Direct Express® Debit MasterCard®, or Neither if they must continue to receive a paper check for the time being.

  • Delete current item 68. Hardship information will no longer be secured by RRB.

• Renumber items.

• Other minor editorial changes.

Form AA-19a, Application for Determination of Child's Disability, which is used to obtain information about a child's medical condition, medical care, education training and work activity, is completed by, or on behalf of, a child over age 18 who became permanently disabled before age 22. Medical evidence is secured as explained in the AA-17b section above.

Since the existence of an eligible disabled child may increase the annuity of an employee applicant or help a spouse or a widow(er) establish eligibility on the basis of having responsibility for the care of a disabled child over age 18 (16 in some cases), Form AA-19a is used as a supplement to survivor application Forms AA‑18 and AA-19; retirement application Form AA-3, Application for Spouse/Divorced Spouse Annuity (OMB No. 3220-0042); and retirement Special Guarantee Form G-319, Statement Regarding Family and Earnings for Special Guaranty Computation (OMB No. 3220‑0083).

Form AA-19a is designed for self-administration. Items 1-9 are pre-filled by the RRB with identifying information before the form is mailed to the applicant for completion. The Paperwork Reduction Act and Privacy Act Notices are found on the form.

After the application is completed, the applicant must read, sign, and date the application’s Certification page, which carries the required fraud language and lists events that could affect their annuity and must be reported to the RRB.

The completed application is then returned to the field office in the pre-addressed return envelope included for that purpose. After the application is released, a Receipt for Claim is provided to the applicant. This receipt advises that processing of the application has begun and provide a general description of the application process; a reminder of events that could affect the annuity and must be reported to the RRB; and RRB telephone numbers to report any events or changes.

The RRB proposes no changes to Form AA-19a.

Form AA-20, Application for Parent's Annuity, which is used when the applicant is applying for a parent's annuity, obtains information about the applicant’s marital history, children, work history, and benefits from other governmental agencies.

Manual Form AA-20 is designed for self-administration by an applicant, or by a representative on behalf of an applicant. Items 1-6 are pre-filled by the RRB with identifying information before the form is mailed to the applicant for completion.

The completed application(s) is then returned to the field office in the pre-addressed return envelope included for that purpose and entered into the APPLE system. After the application is released, Form AA-17rec, Receipt for Claim, is generated and provided to the applicant. This receipt advises that processing of the application has begun and provide a general description of the application process; a reminder of events that could affect the annuity and must be reported to the RRB; and RRB telephone numbers to report any events or changes.

The RRB proposes the following changes to Form AA-20.

• Delete current item 55, which asks if the application is being returned in September, October, November or December. The information is no longer needed.

• Due to the Department of Treasury’s initiative to discontinue issuing paper checks, and to offer alternative payment methods,

  • Modify the title of Section 9 from “Direct Deposit” to “Receiving Your Payments.”

  • Rewrite the introduction below the Section 9 title to include a reference to the Direct Express® Debit MasterCard® as a new option.

  • Create new item 70 to request the applicant choose a method of payment; Direct Deposit, Direct Express® Debit MasterCard®, or Neither if they must continue to receive a paper check for the time being.

  • Delete current item 76. Hardship information will no longer be secured by RRB.

• Renumber items.

• Other minor editorial changes.

Along with each manual form mailed (AA-17, AA-17b, AA-18, AA-19, AA-19a, and AA-20), the applicant receives an application package that includes an RL-1s transmittal letter and booklets RB‑3, Furnishing Evidence to Support Your Claim, and RB-9s, Events that Affect a Survivor Annuity. The RL-1s transmittal letter tells the applicant what forms and booklets should be enclosed in the package and what proofs are needed to support the claim. Booklet RB-3 explains the types of documents which can serve as evidence and gives suggestions for obtaining them. Booklet RB-9s describes events that could cause changes in entitlement or the amount of an annuity and must be reported after the annuity is awarded. When appropriate, the following booklets, are also enclosed to provide important information which the applicant needs to complete an application properly and to explain what the RRB does after receiving the annuity application.

Booklet RB-17, Survivor Annuities - For use with Forms AA-17, AA-18, AA-19, and AA-20. This booklet, contains the Paperwork Reduction Act and Privacy Act Notices associated with the AA-17 application process.

Booklet RB-17b, Widow(er)'s Disability Benefits Booklet - For use with Form AA-17b.

Booklet RB-19a, Child Disability Benefits - For use with Form AA-19a.

Electronic Forms

Since April 2001, the RRB has used the on-line APPLE (Application Express) system to automate the survivor annuity application (AA-17, AA-18, AA-19 and AA-20) process (first approved for use by OMB 3/27/2001). The on-line AA-17 application process is used when an RRB representative interviews an applicant, either at an RRB field office (preferred), an itinerant point, or by telephone, then enters the information into the APPLE system.

The on-line AA-17 collects essentially the same information as the manual AA-17, however, it consists of a script or a series of questions. Depending on the responses to the questions, the APPLE system automatically generates the next appropriate question, eliminating the confusion associated with the skip patterns (“go to items”) that are on the paper version. The APPLE system automatically pre-fills identifying information in real time from RRB database records onto the on-line screens. Depending on the type of survivor benefits being filed, the information provided on manual Forms AA‑18, AA‑19, and AA-20 is incorporated as well as information currently collected on RRB Form AA-8, Application for Medicare (OMB 3220‑0082), and Form G-208, Public Service Pension Questionnaire (OMB 3220-0136), when appropriate. The direct entry of the interview data into the APPLE system expedites the payment process, thereby enhancing RRB customer service goals.

Form AA-17cert, Application Summary and Certification, is generated by the APPLE system upon completion of the on-line AA-17 application process for the applicant to review the information provided or verified, and sign with a traditional pen-and-ink “wet” signature. If the application interview is taken over the telephone, the Form AA-17cert is mailed to the applicant for review and signature. The RRB does not release the application for processing by the payment systems until the signed AA-17cert is returned by the applicant.

Form AA-17cert is divided into three parts:

• Part 1 summarizes information about the employee.

• Part 2 summarizes information about the applicant.

• Part 3 provides for the certification and signature of the applicant and corresponds to Section 10 of the manual Form AA-17. It includes statements that the information given with regard to the application is true; that the applicant received and reviewed a summary of the information they provided; that the applicant received the correct booklets; that the applicant is obligated to advise the RRB of any errors in the summary they received; and that they know if they make a false or fraudulent statement they are committing a crime punishable under Federal Law.

A footer on each page includes the form number, the page number, and a unique identifier. The unique identifier consists of the employee’s social security number, the application type code, and the time and date of generation.

The RRB proposes the following changes to Form AA-17cert.

• Move reference to “grandchild” from current item 12 into new item 13.

• Due to the Department of Treasury’s initiative to discontinue issuing paper checks, and to offer alternative payment methods:

  • Create new item 23 to identify applicants who have selected to receive their payments by Direct Express® Debit MasterCard®.

  • Renumber current item 22 to item 24 and revise language to remove “You have requested…” since there is no payment method to request paper checks be sent to a home address.

• Other minor editorial changes.

NOTE: Two versions of the proposed Form AA-17cert are attached. One version contains all possible statements. The other version is an example of a completed application, which includes only statements relevant to the application process. The annuitant and any personally identifiable information contained in these two versions are fictitious.

After the on-line survivor application (AA-17, AA-17b, AA-18, AA-19, AA-19a, and AA-20) is released, Form AA-17rec, Receipt for Claim, is provided to the applicant. This receipt advises that processing of the application has begun and provides a general description of the application process; a reminder of events that could affect the annuity and must be reported to the RRB; and RRB telephone numbers to report any events or changes.

(Proposed) Form AA-17sum, Application Summary, will be generated by the APPLE system, upon completion of the on-line AA-17 application process, for the applicant to review the information provided or verified, when using the alternative signature method, Attestation. Attestation refers to an action taken by an RRB representative to confirm and annotate in the RRB’s records (1) the applicant’s intent to file an application, (2) the applicant’s affirmation under penalty of perjury that the information provided is correct, and (3) the applicant’s agreement to sign the application by proxy. If the application interview is taken over the telephone, the Form AA‑17sum is mailed to the applicant for review. The RRB office does not release the application for processing by the payment systems until 10 days after Form AA‑17sum is mailed to the applicant.

Form AA-17sum is divided into three parts:

 Part 1 summarizes information about the employee.

 Part 2 summarizes information about the applicant.

 Part 3, which corresponds to the information provided on Form AA-17rec, provides a general description of the application process; a reminder of the events that could affect the annuity and must be reported to the RRB; and the RRB telephone numbers to report any events or changes.

A footer on each page includes the form number, the page number, and a unique identifier. The unique identifier consists of the applicant’s social security number, the application type code and the time and date of generation.

NOTE: Two versions of the proposed Form AA-17sum are attached. One version contains all possible statements. The second version is an example of a completed application that includes only the relevant responses. The annuitant and any personally identifiable information contained in these two versions are fictitious.

In addition to the required review under the Paperwork Reduction Act, proposed Form AA‑17sum was reviewed by staff from the RRB’s Office of General Counsel (OGC) and Office of the Inspector General (OIG). The OGC’s comments were incorporated into the proposed form making it legally acceptable. The OIG provided no comments or objections. Subsequently, the new form has been reviewed and approved for use (pending OMB approval) by the RRB’s Board Members.

3. Planned use of improved information technology or technical/legal impediments to further burden reduction - The RRB has used the APPLE (Application Express) system to automate the survivor benefit application process since OMB approval on 3/27/2001. Implementation of the APPLE system has significantly expedited the payment of survivor claims while reducing respondent burden. Note: RRB Forms AA-17b and AA-19a, are not scheduled for automation due to the need for a face-to-face interview with the applicant and low volume.

4. Efforts to identify duplication - This information collection does not duplicate any other information collection.

5. Small business respondents - N.A.

6. Consequences of less frequent collection - Not applicable since the information is collected only once from each respondent.

7. Special circumstances - N.A.

8. Public comments/consultations outside the agency - In accordance with 5 CFR 1320.8(d), comments were invited from the public regarding the information collection. The notice to the public was published on page 1093 of the January 9, 2012, Federal Register. No comments/requests for additional information were received.

9. Payments or gifts to respondents - None

10. Confidentiality - Privacy Act System of Records RRB-22, Railroad Retirement, Survivor and Pensioner Benefit System. In accordance with OMB Circular M-03-22, a Privacy Impact Assessment for this information collection was completed and can be found at http://www.rrb.gov/pdf/PIA/PIA-BPO.pdf.

11. Sensitive questions - N.A.

12. Estimate of respondent burden -The current and revised estimated annual burden for this collection is as follows:

Current Burden

Form Number	Annual Responses	Time (Minutes)	Burden (Hours)
AA-17 (without assistance)	100	47	78
AA-17b (total)	300 280 20	40 50	204 187 17
(with assistance)
(without assistance)
AA-17cert	3,000	20	1,000
AA-18 (without assistance)	12	47	9
AA-19 (without assistance)	9	47	7
AA-19a (total)	300 285 15	45 65	230 214 16
(with assistance)
(without assistance)
AA-20 (without assistance)	1	47	1
Total	3,722		1,529

Proposed Burden

Form Number	Annual Responses	Time (Minutes)	Burden (Hours)
AA-17 (Without assistance)	100	47	78
AA-17b (With assistance) (Without assistance)	280 20	40 50	187 17
AA-17cert AA-17sum	900 2,100	20 19	300 665
AA-18 (Without assistance)	12	47	9
AA-19 (Without assistance)	9	47	7
AA-19a (With assistance) (Without assistance)	285 15	45 65	214 16
AA-20 (Without assistance)	1	47	1
Total	3,722		1,494

Responses Hours

Total burden Change -0- -35

Program Change -0- -35

13. Estimate of annual cost to respondents or record keepers - N.A.

14. Estimated cost to Federal Government - N.A.

15. Explanation for change in burden - Implementing “Attestation” requires the creation of new Form AA-17sum. We anticipate 2,100 of the 3,722 applicants currently using the AA-17cert, will use “Attestation,” resulting in a decrease in the number of Forms AA-17cert used to 900. We also propose that using “Attestation” will take one minute less to complete, decreasing the burden by 35 hours, from 1,529 to 1,494. We have shown the decrease in burden hours as a program change.

16. Time schedule for data collection and publication - The results of this collection will not be published.

17. Request not to display OMB expiration date - The forms associated with this collection are seldom revised. Given the costs associated with redrafting, reprinting and distributing the forms in order to keep the appropriate OMB expiration date in place, the RRB requests authorization to not display the expiration date on the forms.

18. Exceptions to Certification Statement - None

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