AA-3cert Application Summary and Certification

Form Approved
OMB 3220-0042

United States of America
Railroad Retirement Board

APPLICATION SUMMARY and CERTIFICATION
RR Claim No.
Employee's Name
Social Security Number
Date of Birth

A 813-1 1-1920
Lance Carter
813-1 1-1920
0812811939

The following information was either supplied by or verified by you in support of your application for
Spouse 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.
Applicant lnformation
Leighanne Carter
215 Backstreet Market
Orlando FI 02202

Name and Address

m
Social Secilrity Ni ~ ber
Date of Birth
Daytime Telephone Number
Type of Application Filed Spouse Annuity
You have requested that any payment due you be sent to the address shown above.
Applicant's Marriages
You are currently married to or separated from the employee.
You were ~ i omarried
t
before your marriage to the employee.
Criminal Offense lnformation
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 Iiave not filed nor do you plan to file in the next three months for Social Security benefits on any
account number.
RRB Form AA-3cert (09-07)

32948 64790 22000 06051 32704

Page 1

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0042

You are not receiving a social security benefit.
In the past month you have not filed nor do you plan to file in the next three months for Railroad
Retirement benefits on any other account number.
You are not receiving a railroad retirement annuity.
You are not receiving nor do you expect to receive a pension or lump-s1.1m payment based on your
earnings from a Federal, state or local government agency.
Earnings Information

In 2009, you expect your total earnings will be less than $14,160.
Railroad Work and NonRaClroad Work

You have not worked for a railroad or other employer in the railroad industry.
You have worked for the following employers outside the railroad industry in the six months before
you expect your annuity to begin:
Jive Records

froni 0412811993 to 01I2012009

Beginning Dates and Filing Dates

You requested your annuity begin on the earliest date permitted by law, even if you will receive a
reduced annuity.
You do not want this application to protect your filing date for Social Security benefits.

Application for Spouse Annuity - Certification
Employee's RR Claim Number
Employee's Name
Employee's Social Security Number

A 813-11-1920
Lance Carter
813-1 1-1920

Applicant's Name
Applicant's Social Security Number

Leighanne Carter
885-52-0215

RRB Form AA-3cert (09-07)

32948 64790 22000 06051 32704

Page 2

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0042

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
or withhold information, 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 sun-lmaryof 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-30 Spouse Annuity, RB-9 Employee and Spouse
Annuities - Events that Must be Reported and form G-77a How Work Affects Your Railroad
Retirement Benefits. I understand that I am responsible for reporting events that would affect lily
annuity. Failure to report any of the events that niay affect niy annuity, niay result in a penalty
deduction from my annuity, criniinal a~idlorcivil prosecution.
I agree to immediately notify the RRB, if
My marriage to the employee ends in death or divorce.
I receive a lump sum payment or begin to receive a monthly pension based on my earnings
from a Federal, state or local governnient agency.
I file for social security benefits on any person's account.
I go to work for a railroad or railroad labor organization or work in any capacity in the railroad
industry.
I return to work for Jive Records.
I earn over the annual earnings exempt amount.
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.).
I become a corporate officer of, ow11or operate a corporation, (including a corporation owned
by a family member or friend), whether for pay or not.
I receive anything of value in lieu of salary or wages for any work that I perform.
My address changes.
My bank account changes.
I am confined to a jail, prison, penal institution, or correctional institution due to a conviction
for a criminal offense.

Signature (First Name, Middle Initial, Last Name)
RRB Form AA-3cert (09-07)

32948 64790 22000 06051 32704

Date (MonthIDayNear)
Page 3

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0042

If this certification is signed by mark ("X),two witnesses who know the person signing must sign below, giving theirfull 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)

(-

1

Daytime Telephone Number

RRB Form AA-3cert (09-07)

32948 64790 22000 06051 32704

1-(
Daytime Telephone Number

Page 4