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pdfUNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD
FORM APPROVED
OMB NO. 3220-0042
DO NOT WRITE IN THIS SPACE
OFFICIALLY FILED
DAY
MONTH
Link to RB-30 Booklet on Internet
APPLICATION FOR
SPOUSE/DIVORCED
SPOUSE ANNUITY
OFFICE NUMBER
APPROVED
APPLICATION NUMBER
Though they prefill automatically, you can
complete Items 1-6 below manually.
Section 1
YEAR
DATE CODED
DAY
MONTH
YEAR
CODED BY
General Instructions
Before you complete this application, be sure to read the booklet RB-30, Spouse/Divorced Spouse Annuity, which explains information
you will need to answer many of the questions in this application. Also be sure to read the important notices at the end of the booklet
RB-30.
Type or print legibly in ink. If you need more space than is provided to answer a question, use Section 15 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, 2009, as:
Month
Day
Year
0 6 0 6 2 0 0 9
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.
Section 2
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.
Employee
Identification
Applicant
Identification
1
EMPLOYEE’S RAILROAD RETIREMENT CLAIM NUMBER
2
EMPLOYEE’S SOCIAL SECURITY NUMBER
3
EMPLOYEE’S NAME
4
APPLICANT’S NAME
5
MAILING ADDRESS
CITY AND STATE
ZIP CODE
6
DAYTIME TELEPHONE NUMBER
Form AA-3 (05-10) Destroy Prior Editions
Information About You And Your Family
Section 3
Social
Security
Information
7
Enter your social security number.
–
J To be submitted
If none, enter an “X” by “To be submitted.”
8
9
J
J
Enter an “X” in the appropriate box:
My name appears on my social security card
exactly as it does in Item 4.
Go to Item 10
No
Go to Item 9
MALE
FEMALE
Month
Day
Year
Month
Day
Year
11 Enter your date of birth.
Name At
Birth
12 Enter your name at birth if
different from Item 4.
Current
Marriage
13 Enter the date of your marriage
to the railroad employee.
Marital
Status
14 Enter an “X” in the appropriate box:
Marital status to the railroad employee.
J
J
15 Enter an “X” in the appropriate box:
The railroad employee was married
before our marriage.
J
J
16 Enter an “X” in the appropriate box:
I was married before my marriage
to the railroad employee.
J
J
Subsequent 17 Enter an “X” in the appropriate box:
Marriage
I was married after my marriage
J
J
to the railroad employee.
Marriage
History
Yes
J
J
10 Enter an “X” in the box that shows your sex.
Previous
Marriage
Go to Item 10
Enter your name as it appears on your
social security card.
Sex
Birthdate
Go to
Item 8
–
MARRIED
Go to Item 15
DIVORCED
Go to Item 17
Yes
No
Yes
Go to Item 18
No
Go to Item 19
Yes
No
18 If you are a spouse, enter the following information about your marriage before your marriage to the employee.
If you are a divorced spouse, enter the following information about your marriage after your marriage to the
employee. If applicable, enter information for more than one marriage in Section 15.
Marriage Ended
Marriage Began
a
1. Date
5. Date
2. City and State
6. City and State
3. Former Spouse’s Name
7. Reason J Death
J Divorce J Annulment
J Other - Explain in Section 15
4. Former Spouse’s Social Security Number
–
–
Complete 18b if you do not know your former spouse’s social security number.
b
Month
Enter your former spouse’s
(1) Date of birth
(2) Place of birth
(3) Father’s name
(4) Mother’s maiden name
Form AA-3 (05-10)
Page 2
Day
Year
Criminal
Offense
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.
J
Yes
Go to Item 20
J
No
Go to Section 4
Month
Day
Year
Month
Day
Year
Month
Day
Year
20 Enter the date of the conviction.
21 Enter the date of the sentence of
confinement.
22 Enter the date that confinement began.
J
J
23 Enter an “X” in the appropriate box:
Has the confinement ended?
Yes
Go to Item 24
No
Go to Section 4
Month
Day
Year
24 Enter the date confinement ended.
Section 4
Information About Type Of Annuity
Please read Parts I & III of the RB-30 booklet for information about spouse and divorced spouse annuities and reductions for
early retirement.
Type of
Annuity
25
J
J
Enter an “X” in the box that shows the type of
spouse annuity you are filing for.
J
J
26 Enter an “X” in the appropriate box:
I will accept a reduced age annuity if
I am not eligible for a full age annuity
or an annuity based on child(ren).
Section 5
J
J
FULL AGE ANNUITY
ANNUITY BASED ON
CHILDREN
REDUCED AGE
ANNUITY
DIVORCED SPOUSE
WITH PREVIOUS
AGE REDUCTION
}
Go to
Item 26
}
}
Go to
Section 5
Go to
Section 6
Yes
No
Information About Children In Your Care
Please read Part I of the RB-30 booklet for an explanation of “child-in-care.”
Filing
Based On
Child-InCare
27 Enter an “X” in the appropriate box:
I have one or more of the railroad employee’s
children in my care who are unmarried and under
age 18. (This includes natural children, adopted
children, stepchildren and dependent
grandchildren.)
Page 3
J
Yes
Go to Item 28
J
No
Go to Item 33
Form AA-3 (05-10)
Children
Print the requested information for every child in your care who would count toward qualifying you for an annuity.
Print the youngest child in 28, the second youngest in 29, and so on. If a child does not have a social security
number, enter “TO BE SUBMITTED.”
Child’s Full Name and
Social Security Number
28a Name
Relationship to Employee
(Check One)
28c
28b
29a Name
29c
29b
30c
30a Name
30b
31a Name
31c
31b
32a Name
32c
32b
K
K
K
K
K
K
K
K
K
K
K
K
K
K
K
K
K
K
K
K
K
K
K
K
K
Natural
Adopted
Stepchild
Grandchild
Other
Natural
Adopted
Stepchild
Grandchild
Other
Natural
Adopted
Stepchild
Grandchild
Other
Natural
Adopted
Stepchild
Grandchild
Other
Natural
Adopted
Stepchild
Grandchild
Other
Enter an ”X” in the
appropriate box:
The child is disabled
Date of Birth
28e
28d
Month
Day
Year
Day
Year
Day
Year
Day
Year
Day
Year
29e
29d
Month
30e
30d
Month
31e
31d
Month
32e
32d
Month
K Yes
K No
K Yes
K No
K Yes
K No
K Yes
K No
K Yes
K No
Note: To support your entitlement to a spouse annuity based on having a disabled child in your care,
either you or the employee must complete and return to the RRB Form AA-19a, Application for
Determination of Child’s Disability, for each disabled child listed in Items 28-32.
Do not complete Item 33 if every child in items 28-32 is living with you; go to Section 6.
Children
Not Living
With
Applicant
33 Print the requested information for every child not living with you. Print the youngest child in (a).
Explain your parental responsibilities in Section 15.
Full Name
Of Child
Person With Whom Child Now Lives
Child’s Address
Name
a
b
Note: Items 34-45 are reserved.
Section 6
Information About Your Railroad Work
Please read Part II of the RB-30 booklet for an explanation of work that you must stop.
Railroad
Work
Last
Railroad
Employment
46 Enter an “X” in the appropriate box:
I have worked for a railroad or other employer in the
railroad industry or a railroad labor organization.
47 Enter the name of the railroad company or railroad
labor organization that last employed you.
48 Enter your payroll name and identification
number for that employer. (If you did not
work for the employer named in Item 47 this
year or last year, leave this item blank.)
49 Enter your last job title for that employer.
(If you did not work for the employer named
in Item 47 this year or last year, leave this
item blank.)
Form AA-3 (05-10)
Page 4
J
J
Yes
Go to Item 47
No
Go to Section 7
Relationship
To Child
Last
50
Railroad
Employment
(Cont.)
Enter your last division or department
and its location for that employer.
Other
Railroad
Work
TO
FROM
51 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.)
Month
Day
Year
52 Enter an “X” in the appropriate box:
I relinquish my seniority rights and all other
rights to work for the employer shown in Item 47
as of the last date entered in Item 51.
J
J
53 Enter an “X” in the appropriate box:
I have worked for another railroad or other
employer in the railroad industry or a railroad
labor organization this year or last year.
J
J
Month
Day
Year
Yes
No
Yes
Go to Item 54
No
Go to Item 60
54 Enter the name of that employer.
55 Enter your payroll name and Identification
number for that employer.
56 Enter your last job title for
that employer.
57 Enter your last division or department
and its location for that employer.
58 Enter the dates you worked for the employer
named in Item 54. (If your railroad employment
has not ended, enter the last date you will work
for this employer in the “TO” date.)
Railroad
Seniority
Rights
FROM
Month
Day
TO
Year
59 Enter an “X” in the appropriate box:
I relinquish my seniority rights and all other
rights to work for the employer shown in
Item 54 as of the last date entered in Item 58.
J
J
60 Enter an “X” in the appropriate box:
I still have seniority rights or other rights to return
to work for a railroad employer or a railroad labor
organization not listed in Items 47 or 54.
J
J
Month
Day
Year
Yes
No
Yes
Go to Item 61
No
Go to Section 7
61 Enter the name and address of any additional
employer indicated in Item 60 with whom you
still have rights to return to work.
Note: Your spouse annuity cannot begin until you relinquish your rights to employment
with the employer(s) named in Items 47-61.
Page 5
Form AA-3 (05-10)
Information About Your Nonrailroad Work
Section 7
Do not complete this section if you are filing for a divorced spouse annuity.
Nonrailroad
Work
Please read Part IV of the RB-30 booklet for information about nonrailroad work and how employment affects your
annuity.
62
Enter an “X” in the appropriate box:
I worked for pay outside the railroad industry within the 6
months before the date I expect my annuity to begin. (Do
not include self-employment. Include any employment for
an incorporated business which you own or public service.)
J Yes
Go to Note and Item 63
J
Go to Item 73
No
Note: If you had Last Pre-Retirement Nonrailroad Employment (LPE) after your annuity would begin,
complete Form G-19F, Earnings Information Request, only when one of the following applies:
(1) The annuity beginning date (ABD) is before January 1 of this year or
(2) the ABD is January 1, or later, of this year, and you ceased working in LPE after the ABD month.
Most Recent
Nonrailroad
Work
63
Enter the name and address of your current or most
recent nonrailroad employer.
64
Enter your current or most recent job title
for that employer.
65
Enter your average monthly salary for that employer.
(SHOW DOLLARS ONLY)
66
Enter the dates you worked for that
employer. (If you have not set the date
you expect to stop working, leave the
“TO” date blank and check the box
“I am still working.”)
67
Next Most
Recent
Nonrailroad
Work
SelfEmployment
FROM
Month Day
Enter an “X” in the appropriate box:
The employer named in Item 63 is a seasonal employer.
68
Enter the name and address of your next most
recent nonrailroad employer within the 6 months
before the date you expect your annuity to begin.
69
Enter your last job title for that employer.
70
Enter your average monthly salary for that employer.
(SHOW DOLLARS ONLY)
71
Enter the dates you worked for that
employer. (If you have not set the date
you expect to stop working, leave the
“TO” date blank and check the box
“I am still working.”)
72
$
J
I am still working
J
J
Yes
TO
Month Day
If none, enter “NONE” and go to Item 73
$
Year
J
I am still working
J
J
Yes
TO
Month Day
No
If you are employed and your business is incorporated, answer Item 73 “No.” Make sure Items 62-72 are also
completed. If your business is not incorporated, answer Item 73 “Yes” and go to Item 74.
73
J Yes
J No
Enter an “X” in the appropriate box:
I was self-employed during the last
6 months.
Go to Item 74
Go to Section 8
Note: If answered “Yes,” complete and return Form AA-4, Self-Employment and Substantial Service
Questionnaire, to the RRB.
Form AA-3 (05-10)
Page 6
Year
No
FROM
Month Day
Enter an “X” in the appropriate box:
The employer named in Item 68 is a seasonal employer.
Year
Year
SelfEmployment 74
(Cont.)
J
J
Enter an “X” in the appropriate box:
I am still self-employed.
Go to Section 8
No
Go to Item 75
Month
75 Enter the date you were last
self-employed.
Section 8
Yes
Day
Year
Information About When Your Annuity Will Begin
Please read Part II of the RB-30 booklet to find out how your annuity beginning date is determined.
Annuity
Beginning
Date
J
J
76 Enter an “X” in the appropriate box:
I want my annuity to begin on the
earliest date permitted by law.
Yes
Go to Section 9
No
Go to Item 77
Month
Day
Year
77 Enter the date you want your annuity to begin.
Section 9
Information About Your Earnings
Before answering Items 78-90, please read Part IV of the RB-30 booklet to find out how earnings can affect your annuity.
For the exempt amounts, refer to Form G-77a, How Work Affects Your Railroad Retirement Benefits.
Earnings
Last
Year
________
(Year)
78 Enter an “X” in the appropriate box:
I expect my annuity to begin before
January 1 of this year.
J
J
79 Enter an “X” in the appropriate box:
My total earnings from all employment
last year were more than the annual
earnings exempt amount.
J
J
80 Enter your total earnings for last year.
(SHOW DOLLARS ONLY)
Go to Item 79
No
Go to Item 83
Yes
Go to Item 80
No
Go to Item 83
Yes
Go to Item 83
No
Go to Item 82
$
81 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.
J
J
82 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
_______
(Year)
Yes
83 Enter an “X” in the appropriate box:
I expect my total earnings for 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.”)
84 Enter the total amount you expect
to earn this year.
(SHOW DOLLARS ONLY)
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
J
J
Yes
Go to Item 84
No
Go to Item 87
$
Page 7
Form AA-3 (05-10)
Earnings
This Year
(Cont.)
85 Enter an “X” in the appropriate box:
I expect to earn more than the monthly earnings
exempt amount in employment for hire or to
perform substantial services in self-employment in
every month this year.
J
J
86 Enter an ”X” next to each month this year in which
you did not, or do not expect to, earn the monthly
earnings exempt amount or perform substantial
services in self-employment.
Earnings
Next Year
_______
(Year)
No
Go to Item 86
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
J
J
88 Enter an “X” in the appropriate box:
I expect my total earnings for all employment
next year to be more than this year’s annual
earnings exempt amount.
J
J
Yes
Go to Item 88
No
Go to Section 10
Yes
Go to Item 89
No
Go to Section 10
$
90 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.
Section 10
Go to Item 87
JAN
87 Enter an “X” in the appropriate box:
I am filing this application in
September, October, November, or December.
89 Enter the total amount that you expect
to earn next year.
(SHOW DOLLARS ONLY)
Yes
JAN
FEB
MAR
Information About Social Security Benefits
Please read Part V of the RB-30 booklet to see how this application can protect your rights to social security
benefits, and to see what effect social security benefits will have upon your railroad retirement annuity.
Social
Security
Filing Date
Social
Security
Benefits
91 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.)
J
J
92 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.
J
J
No
Yes
Go to Item 93
No
Go to Section 11
Year
Month
93 Enter the date you became or will become
eligible for these social security benefits.
94 Enter an “X” in the appropriate box:
I have received my first social security payment.
95 Enter the current total monthly amount of
your social security benefits (before
reduction for work or Medicare premiums).
Form AA-3 (05-10)
Yes
J
J
$
Page 8
Yes
Go to Item 95
No
Go to Item 96
APR
Social
Security
Benefits
(Cont.)
96 Enter an “X” in the appropriate box:
All or part of my social security benefits
described above are based on the earnings
of someone other than the railroad
employee or myself.
J
J
Yes
Go to Item 97
No
Go to Section 11
97 Enter the social security number of the person on whose
earnings your social security benefits are based.
98 Enter the name of the person on whose earnings
your social security benefits are based.
Section 11
Information About Other Railroad Retirement Annuity
Please read Part V of the RB-30 booklet for an explanation of the reduction for other railroad retirement annuities.
Other
Railroad
Annuity
99
Enter an ”X” in the appropriate box:
I previously filed, or I am now filing for a
separate railroad retirement annuity based
on an earnings record of someone other than
the railroad employee named in Item 3.
(Include yourself if applicable.)
J
J
Yes
Go to Item 100
No
Go to Section 12
100 Print the full name of that other person.
Section 12
If only six numbers,
enter here:
Prefix
101 Enter that other person’s Railroad
Retirement Board claim number,
including the letter prefix.
Information About Public Service Pension
Please read Part V of the RB-30 booklet for an explanation of the reduction for a Public Service Pension.
Public
Service
Pension
102 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 a 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.)
J
J
103 Enter an “X” in the appropriate box:
I am/was an employee of the Federal Government.
J
J
Yes
Go to Item 103
No
Go to Section 13
Yes
Go to Note and Section 13
No
Go to Item 104
Note: If answered “Yes,” complete and return to the RRB, Form G-208, Public
Service Pension Questionnaire, and verification of your pension.
Page 9
Form AA-3 05-10)
Public
Service
Pension
(Cont.)
104 Enter an “X” in the appropriate box:
In the last 60 months 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.
J
J
Yes
Go to Section 13
No
Go to Note and Section 13
NOTE: If answered “No,” complete and return to the RRB, Form G-208,
Public Service Pension Questionnaire, and verification of your pension.
Section 13
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-30 booklet for an explanation of the Medicare program.
Medicare
105 Enter an “X” in the appropriate box:
Enrollment
I have a Medicare card that shows entitlement
to Medicare medical insurance (Part B).
106 Enter your Medicare claim number.
(If this is a railroad retirement filing, enter the prefix.
If it is a social security filing, enter the suffix.)
J
J
Yes
Go to Item 106
No
Go to Item 107
Prefix
Suffix
Go to Section 14
107 Enter an “X” in the appropriate box:
I have filed for Part B within
the last three months.
J
J
108 a 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 it
is a social security filing, enter the suffix.)
Yes
Go to Item 108a
No
Go to Item 109
Prefix
Suffix
Month
Day
Year
b Enter the date you filed.
109 Enter an “X” in the appropriate box:
I wish to enroll in Part B.
Go to
Section 14
J Yes
J
110 Enter an “X” in the appropriate box:
I am currently covered by an employer group health
plan (EGHP) based on my own or my spouse’s
current employment.
J
J
111 Enter an “X” in the appropriate box:
I was previously covered by an EGHP based on my
own or my spouse’s current employment.
J
J
If you are under age 65 years
and 4 months, go to Section 14.
If you are older than age 65 years and 3
months, go to Item 110.
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 14.
Yes
Go to Item 112
No
Go to Item 111
Yes
Go to Item 113
No
Go to Section 14
Month
Day
Year
Month
Day
Year
112 The beginning date of my EGHP coverage is:
If applicable, the date employment will stop for the
person whose employment qualifies me for EGHP
coverage is:
Form AA-3 (05-10)
Page 10
Go to Item 114
Medicare
Enrollment 113 The beginning and ending dates of my EGHP
coverage and the date last worked in the employment
(Cont.)
Month
Day
Year
which qualified me for EGHP coverage are:
EGHP Beginning Date
EGHP Ending Date
Date Employment Stopped
Go to Item 114
114 Enter an “X” in the appropriate box:
I wish to enroll in a special enrollment period.
J
J
115 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.
J
J
Yes
Go to Item 115a
No
Go to Item 116
Yes
Go to Item 115b
No
Go to Section 14
Month
Day
b. I am requesting a Part B effective date of
J
J
116 Enter an “X” in the appropriate box:
I am requesting premium surcharge relief
for the months of EGHP coverage.
Section 14
Year
Go to
Section 14
Yes
No
Direct Deposit
Please read Part VII of the RB-30 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 15, or call your financial institution for the information you need to complete Items 117-121, below. If you
do not have a bank account, or if you believe receiving your payments by Direct Deposit would cause you a hardship,
go to Item 122.
Direct
Deposit
117 Enter the name of your financial institution.
Area Code
118 Enter the telephone number of your
financial institution.
Telephone Number
119 Enter the routing transit number of your financial institution.
120 Enter your account number.
121 Enter an “X” in the appropriate box:
Type of account for the above account number.
J
J
Checking
Savings
Go to Section 15
122 Check this box if you do not have a checking
or savings account, or if Direct Deposit would
cause you a hardship.
Page 11
J
Form AA-3 (05-10)
Section 15
Remarks
Remarks
123 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.
Form AA-3 (05-10)
Page 12
Certification
Section 16
Certification 124
J
J
Enter an “X” in the appropriate box:
I will have a guardian or other representative
sign this application on my behalf.
YES
Go to Note and Item 125
NO
Go to Item 125
Note: If 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.
125
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. I have received the booklets, RB-30,
Spouse/Divorced Spouse 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 go to work for a railroad or railroad labor
organization, or return to work in any capacity in the
railroad industry.
•
•
IF I remarry (if I am filing for a divorced spouse annuity).
•
IF I am filing in advance of the date(s) shown in
Item(s) 51 (and 58), and there is a change in a date.
IF my address changes.
•
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) 51 (and 58).
•
•
•
•
IF I earn more than the annual earnings exempt amount.
•
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.
•
•
IF I return to work for my Last Pre-Retirement
Nonrailroad Employer and there is a change in
my estimated earnings.
•
IF I begin to receive benefits directly from the Social
Security Administration.
•
IF benefits I receive directly from SSA are adjusted for
a reason other than normal cost-of-living increases.
•
IF I begin to receive a public service pension or there is
a change in the amount of my public service pension.
•
IF my marriage ends in death or divorce (if I am
filing for a spouse annuity).
IF a qualifying child marries or leaves my custody or
residence.
IF I am confined in a jail, prison, penal institution, or correctional facility due to a conviction for a criminal offense.
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.).
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 and/or civil prosecution.
SIGNATURE
(First Name, Middle Initial,
Last Name)
Month
Day
Year
DATE
126 If this certification is signed by mark (“X”) in Item 125, two witnesses who know the person signing must
sign below, giving their full addresses and daytime telephone numbers.
a. Signature of Witness
b. Signature of Witness
Address (Number and Street)
Address (Number and Street)
City, State, ZIP Code
City, State, ZIP Code
Area Code
Telephone Number
Page 13
Area Code
Telephone Number
Form AA-3 (05-10)
Section 17
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 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.
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: 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.
Form AA-3 (05-10)
Page 14
| File Type | application/pdf |
| File Title | AA-3 05-10:AA-3 (04-04).qxd.qxd |
| Author | osikagl |
| File Modified | 2010-12-29 |
| File Created | 2010-05-04 |