AA-3cert (proposed Application Summary and Certfication

PROPOSED (ALL POSSIBLE)

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0042

APPLICATION SUMMARY and CERTIFICATION
Employee’s Name
RR Claim No.
Social Security Number
Date of Birth
The following information was either supplied by or verified by you in support of your
application for (a Spouse Annuity/a Divorced Spouse Annuity/Medicare) 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 Information
Name and Address
Daytime Telephone Number
Social Security Number
Date of Birth
Type of Application Filed

(Spouse Annuity/Divorced Spouse Annuity/
Medicare)

Application Filing Date
1

You applied for this benefit based on your relationship to the employee and you have
the following children in your care.
Name

SS Number

DOB

2

You have requested that any payment due you be sent to the following bank
account:
Bank Name
Routing Number
Account Number
Account Type

3

You have requested that any payment due you be sent using the Direct Express®
Debit MasterCard®. Payments will be sent to the address shown above until the card
is issued.

4

Any payment due you will be sent to the address shown above.

RRB Form AA-3cert (xx-xx)

88552 0215 22000 06051 32704

Page 1

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0042

Applicant’s Marriages
5

You are currently married to or separated from the employee.

6

You were married before your marriage to the employee.

7

You were not married before your marriage to the employee.

8

You have remarried since your divorce from the employee.

9

You have not remarried since your divorce from the employee.

Criminal Offense Information
10

Within the past 12 months you have not been imprisoned or given a sentence of
confinement due to a conviction for a criminal offense.

11

Within the past 12 months you have been imprisoned or given a sentence of
confinement due to a conviction for a criminal offense.

Other Government Benefits
12

You are currently receiving a social security benefit.

13

You have filed or plan to file in the next three months for Social Security benefits on
your own account.

14

You have filed or plan to file in the next three months for Social Security benefits on
the account of:
Name
Social Security Number

15

You have not filed nor do you plan to file in the next three months for Social Security
benefits on any account number.

16

You have not filed nor do you plan to file in the next three months for Social Security
benefits on an additional account number.

17

You are not receiving a Social Security benefit.

18

In the past month you have filed or plan to file in the next three months for Railroad
Retirement benefits based on your own earnings.

RRB Form AA-3cert (xx-xx)

88552 0215 22000 06051 32704

Page 2

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0042

19

In the past month you have filed or plan to file in the next three months for Railroad
Retirement benefits based on the account of:
Name
Claim Number

20

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.

21

You are currently receiving a Railroad Retirement annuity.

22

You are not receiving a Railroad Retirement annuity.

23

You are receiving a pension based on your earnings from a Federal, state or local
government agency.

24

You received a lump-sum payment instead of a monthly pension from a Federal,
state or local government agency.

25

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.

26

You expect to receive a pension or lump-sum payment based on your earnings from
a Federal, state or local government agency.

Earnings Information
27

In (last year), your total earnings were (actual earnings).

28

In (last year), your earnings were less than (annual exempt amount).

29

In (last year), you earned more than (monthly exempt amount) in each month.

30

In (last year), you earned less than (monthly exempt amount) in the following
months:
January February March April May June July August September
October November December

31

In (current year), you expect your total earnings will be (estimated earnings amount).

32

In (current year), you expect your total earnings will be less than (annual exempt
amount).

33

In (current year), you expect to earn more than (monthly exempt amount) in each
month.

RRB Form AA-3cert (xx-xx)

88552 0215 22000 06051 32704

Page 3

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0042

34

In (current year), you expect to earn less than (monthly exempt amount) in the
following months:
January February March April May June July August September
October November December

35

In (next year), you expect your total earnings will be (estimated earnings amount).

36

In (next year), you expect your total earnings will be less than (annual exempt
amount).

Railroad Work and NonRailroad Work
37

You worked for a railroad, railroad labor organization or other employer in the
railroad industry.
Railroad Name
Date Last Worked
Date Rights Relinquished

38

You have not worked for a railroad, railroad labor organization or other employer in
the railroad industry.

39

You worked for the following employers outside the railroad industry in the six
months before you expect your annuity to begin.
(Company Name)
(Company Name)
(Company Name)

from 99/99/9999 to 99/99/9999
from 99/99/9999 to 99/99/9999
from 99/99/9999 to 99/99/9999

40

You have not worked for an employer outside the railroad industry in the six months
before you expect your annuity to begin.

41

You worked for the following employers as a seasonal employee:
(Company Name)
(Company Name)
(Company Name)

42

from 99/99/9999 to 99/99/9999
from 99/99/9999 to 99/99/9999
from 99/99/9999 to 99/99/9999

You were self-employed during the last 12 months.

Beginning Dates and Filing Dates
43

You have requested your annuity begin on the earliest date permitted by law, even if
you will receive a reduced annuity.

44

You have requested your annuity begin on the earliest date permitted by law, as long
as it does not result in a reduced annuity.

RRB Form AA-3cert (xx-xx)

88552 0215 22000 06051 32704

Page 4

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0042

45

You have selected mm/dd/yyyy for the beginning date of your annuity.

46

This application will protect your filing date for Social Security benefits.

47

You do not want this application to protect your filing date for Social Security
benefits.

Medicare
48

You are enrolled in the Medicare Medical Insurance Plan (Part B).

49

You wish to enroll in the Medicare Medical Insurance Plan (Part B).

50

You do not wish to enroll in the Medicare Medical Insurance Plan (Part B) at this
time.

51

You are requesting a special enrollment period based on coverage by an employer
group health plan.

52

You are requesting premium surcharge relief based on coverage by an employer
group health plan.

Application for (a Spouse Annuity/a Divorced Spouse Annuity/Medicare) Certification
Employee’s RR Claim Number
Employee’s Name
Employee’s Social Security Number
Applicant’s Name
Applicant’s Social Security Number

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 under Federal law, which may be punishable by fines,
imprisonment or both.
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 I have made and initialed any corrections on the summary being returned to
the RRB.
RRB Form AA-3cert (xx-xx)

88552 0215 22000 06051 32704

Page 5

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0042

(Printed if application type is Spouse or Spouse with child and spouse is FRA or older.)
I have received and reviewed 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 the
booklets. Failure to report any of the events listed below or other events that may affect
my annuity, may result in a penalty deduction from my annuity, as well as criminal and/or
civil prosecution.
(Printed if application type is Spouse or Spouse with child and spouse is under FRA.)
I have received and reviewed the booklets RB-30, Spouse/Divorced 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 my annuity as explained in the booklets and form.
Failure to report any of the events listed below or other events that may affect my annuity,
may result in a penalty deduction from my annuity, as well as criminal and/or civil
prosecution.
I agree to immediately notify the RRB, if
I remarry.
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 government agency.
The amount of my pension based on my earnings from a Federal, state or local
government agency changes.
I file for social security benefits on any person’s earnings record.
Benefits I receive directly from the Social Security Administration are adjusted for a
reason other than normal cost-of-living increases.
I go to work for a railroad or railroad labor organization or work in any capacity in the
railroad industry.
I am filing in advance and my last date of employment changes.
I return to work for _______________________.
I earn over the annual earnings exempt amount.
My expected earnings amount changes.
I receive a settlement with credit for railroad service as “pay-for-time-lost” for months
after (print date railroad employment ended).
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, own or 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 performed.
RRB Form AA-3cert (xx-xx)

88552 0215 22000 06051 32704

Page 6

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0042

My address changes.
My financial organization or the account number of my financial organization changes.
A child on whose basis I am entitled to an annuity marries, dies or leaves my care and
custody.
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-3cert (xx-xx)

88552 0215 22000 06051 32704

Page 7