AA-3sum (proposed) Application Summary

PROPOSED (ALL POSSIBLE)

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0042

APPLICATION SUMMARY FOR (A SPOUSE ANNUITY/
A DIVORCED SPOUSE ANNUITY/MEDICARE)
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.
Review the information for accuracy. If there are any errors, notify the Railroad Retirement Board
(RRB) immediately, and no later than 10 days from the date you receive this summary.
This information is certified by you to be true and correct to the best of your knowledge. You have
been informed and you acknowledge that making a false or fraudulent statement or withholding
information, in order to receive benefits from the RRB, is a crime under Federal law and may be
punishable by fines, imprisonment or both.
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.

RRB Form AA-3sum (xx-xx)

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United States of America
Railroad Retirement Board

4

Form Approved
OMB No. 3220-0042

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

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.

RRB Form AA-3sum (xx-xx)

88552 0215 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0042

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.

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).

RRB Form AA-3sum (xx-xx)

88552 0215 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0042

33

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

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.

RRB Form AA-3sum (xx-xx)

88552 0215 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0042

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.

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.

(Printed if application type is Spouse or Spouse with child and spouse is FRA or older.)
Your application for (a Spouse Annuity/a Divorced Spouse Annuity/Medicare) has been released
and will be processed as quickly as possible. If you do not receive notification about your
application by (Customer service standard added to application filing date) you should contact the
field office shown below.
You have received and reviewed the booklets RB-30, Spouse/Divorced Spouse Annuity and RB-9,
Employee and Spouse Annuities - Events that Must be Reported. It is your responsibility to report
events that would affect your annuity as explained in the booklets. Failure to report any of the events
listed below or other events that may affect your annuity may result in a penalty deduction from your
annuity, as well as criminal and/or civil prosecution.
(Printed if application type is Spouse or Spouse with child and spouse is under FRA.)
Your application for (a Spouse Annuity/a Divorced Spouse Annuity/Medicare) has been released
and will be processed as quickly as possible. If you do not receive notification about your
application by (Customer service standard added to application filing date) you should contact the
field office shown below.
You 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
RRB Form AA-3sum (xx-xx)

88552 0215 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0042

Affects Your Railroad Retirement Benefits. It is your responsibility to report events that would affect
your annuity as explained in the booklets and form. Failure to report any of the events listed below
or other events that may affect your annuity may result in a penalty deduction from your annuity, as
well as criminal and/or civil prosecution.
(Printed if application type is Medicare only.)
Your application for Medicare has been received and will be processed as quickly as possible.
If you change your address, or if there is some other change that may affect your application, you or
your representative should report the change at once. If you have any questions, we will be glad to
help you. You can report changes either by telephone, mail, or in person, whichever you prefer.
Most Railroad Retirement Board offices are open to the public from 9:00 AM to 3:30 PM, Monday
through Friday.
Always Report These Changes to the RRB
Marriage – If you remarry.
Marriage – If your marriage to the employee ends by death or divorce.
Social Security – If you file for social security benefits based on any person’s earnings record.
Social Security – If benefits you receive directly from the Social Security Administration are
adjusted for a reason other than normal cost-of-living increases.
Public Pension – If you receive a lump-sum payment or begin to receive a monthly pension
based on your earnings at an agency of the Federal, state or local government.
Public Pension – If the amount of your pension based on your earnings from a Federal, state or
local government agency changes.
Earnings – If your earnings change.
On your application you told us you expect your total nonrailroad earnings for (current year) to
be $________.
On your application you told us you expect your total nonrailroad earnings for (current year) to
be less than $________.
You are earning more than $________.
You are not earning more than $________.
Railroad Work – If you go to work for an employer in the railroad industry. (Print on all receipts.)
Employment – If you return to work for _________________________________.
Employment – If you change the date of last nonrailroad employment. On your application you
said your last day of employment with ____________ would be ______________.
Employment – If you cease working for
.
Employment – If you perform work, including self-employment, for a family owned, controlled or
managed business, including a business operated, managed or owned by you, 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.).
Employment – If you 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.
RRB Form AA-3sum (xx-xx)

88552 0215 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0042

Employment – If you receive anything of value in lieu of salary or wages for any work that you
performed.
Settlement – If you receive a settlement with credit for railroad service as “pay-for-time-lost” for
months after _______________.
Address – If your address changes, even if your payments are sent to a financial organization.
Address – If your address changes. (Print if application type is Medicare Only.)
Bank Account – If your financial organization or the account number at your financial
organization changes.
Criminal Offense – If you are confined in a jail, prison, penal institution, or correctional facility
due to a conviction for a criminal offense.
Children in Your Care – If a child on whose basis you are entitled to an annuity marries, dies or
leaves your care and custody.
Death or Disability – Your representative should notify the RRB immediately if you die or
become unable to handle your own benefits.
How to Report Changes
When a change occurs after you have begun receiving your annuity, you should report the change
at once. You or your representative can make the reports by telephone, mail or in person,
whichever you prefer.
(Print if applicant is applying for a spouse benefit and is under FRA.)
In most cases, we calculate how much to reduce your annuity because of your earnings based on
either the earnings estimate you gave us when you applied for benefits, or on reports submitted by
employers to the Social Security Administration. As a reminder, you should report your earnings
(1) when we ask for a report of your earnings or (2) if any of the following happens:
You stop working;
You start working and expect to earn more than the annual exempt amount;
Your employment is not covered under the Social Security Act (i.e., FICA taxes are not
deducted from your pay);
You work for a railroad or railroad labor organization; or
You return to work for your last pre-retirement nonrailroad employer.
To report any changes or ask questions, you should contact:
(Field Office Address and Toll-Free Telephone Number)
If for some reason you are unable to contact that office, you should contact:
U.S. Railroad Retirement Board
844 N Rush Street
Chicago, Illinois 60611-2092
http://www.rrb.gov
RRB Form AA-3sum (xx-xx)

88552 0215 22000 06051 32704

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