AA-3cert (proposed Application Summary and Certification

United States of America
Railroad Retirement Board

PROPOSED (COMPLETED)

Form Approved
OMB 3220-0042

APPLICATION SUMMARY FOR SPOUSE ANNUITY

Employee’s Name
RR Claim No.
Social Security Number
Date of Birth

Lance Carter
A 813-11-1920
813-11-1920
08/28/1939

The following information was either supplied by or verified by you in support of your
application for a 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 Information
Name and Address

Daytime Telephone Number
Social Security Number
Date of Birth

Leighanne Carter
215 Backstreet Market
Orlando Fl 02202
219-201-8552
885-52-0215
02/20/1942

Type of Application Filed

Spouse Annuity

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.
Applicant’s Marriages
You are currently married to or separated from the employee.
You were not married before your marriage to the employee.
Criminal Offense Information
Within the past 12 months you have not been imprisoned or given a sentence of
confinement due to a conviction for a criminal offense.
Other Government Benefits
You have 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 (xx-xx)

88552 0215 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-sum payment based
on your earnings from a Federal, state or local government agency.
Earnings Information
In 2012, you expect your total earnings will be less than $14,640.
Railroad Work and NonRailroad Work
You have not worked for a railroad, railroad labor organization or other employer in the
railroad industry.
You worked for the following employers outside the railroad industry in the six months
before you expect your annuity to begin:
Jive Records

from 04/28/1993 to 01/20/2006

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

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

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

Applicant’s Name
Applicant’s Social Security Number

Leighanne Carter
885-52-0215

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 Form AA-3cert (xx-xx)

88552 0215 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0042

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.
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 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
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.
I file for social security benefits on any person’s earnings record.
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, 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 perform.
My address changes.
My financial organization or the account number of my financial organization
changes.
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)

RRB Form AA-3cert (xx-xx)

___________________
Date (Month/Day/Year)

88552 0215 22000 06051 32704

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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 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 4