AA1cert (proposed)(completed)

Form Approved
OMB 3220-0002

Modified 08-31-2009

APPLICATION SUMMARY and CERTIFICATION
A 813-11-1920
Lance Carter
813-1 1-1920

RRB Claim Number
Name
Social Security Number

The following information was either supplied by or verified by you in support of your
application for an Employee Annuity under the Railroad Retirement Act. After you have
reviewed the information, make any changes on the sun-lmary, initial the change and sign
the certification on the last page. Return the certification and all pages of the summary to
the RRB.
Military Service
I was in active military service after September 7, 1939.
Recent Employment
I did not work for an employer outside the railroad industry in the last 6 months or since
leaving the railroad industry.
Railroad Employment
You have a current connection with the railroad industry.
I have worked for the following railroad or other employer in the railroad industry.
Date Last Worked
Date Rights Relinquished
Railroad Name
08/24/2009
Union Pacific Railroad
0812412009
Lance Carter
215 Backstreet Market
Marathon FI 02202

Name and Address

Date o f Birth
Daytime Telephone Number
Type of Application Filed En-~ployeeAnnuity
I am applying for a benefit based on my age and railroad service
You have requested that any payment due you be sent to the following bank account:
Citibank
Bank Name
Routing Number
2131 11920
RRB Form AA-lcert (xx-xx)

32948 64790 22000 06051 32704

Page 1

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0002

Account Nun-lber
Account Type

1855202152220
Savings,

Marriages
I am currently married,
Family
I do not have unmarried qualifying children.
Other Government Benefits
I am currently receiving a social security benefit.

I have not filed nor do I plan to file the next three months for Social Security benefits on an
additional account number.
In the past month I have not filed nor do I plan to file i ~the
i next tliree nionths for Railroad
Retirement benefits on any other account number.
I am not receiving nor do I expect to receive a pension or lump-sum payment based on
my earnings after 1956 for an employer not covered by Social Security or Railroad
Retirement.
Other Benefits
I expect to receive a railroad pension from Union Pacific Railroad.
Miscellaneous I~iformatio~i
The RRB has not been furnished with a court order to enforce my child support or alimony
obligation.

The RRB has not been furnished with a court order to pay part of my present or future
railroad retirement benefit to a spouse or former spouse as part of a property settlement in
a divorce or legal separation proceeding.
I have not received nor do I expect to receive pay for time lost from my last railroad
en-lployer.
I have not received nor do I expect to receive sick pay, under a wage continuation plan
established through company policy or a labor agreement, for a period after the actual
date I last worked.
Earnings Information
In 2009, you expect your total nor~railroadearnings will be less than $14,160.
RRB Form AA-lcert (xx-m)

32948 64790 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0002

Criminal Offense Information
Within the past 12 months I have not been imprisoned or been given a sentence of
confinement due to a conviction for a criminal offense.
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.
This application will protect your filing date for Social Security benefits.
Application for Employee Annuity - Certification

RR Claim Number
Name
Social Security Number

A 81 3-1 1-1920
Lance Carter
81 3-1 1-1920

I certify that the information I have given to tlie 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 witl- hold informa,tion,in order to receive benefits from the
RRB, I am committing a crime which is pur~ishableunder Federal law.
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 have made and initialed any corrections on the Summary being returned to
the RRB.

I have received and reviewed the booklets RB-1 Age and Senlice Employee Annuity, RRB9 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. Failure to report any of the events that may
affect my annuity, may result in a penalty deduction from my annuity, criminal and/or civil
prosecution.
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 indus,try;
I begin to receive a pension based on earnings that are not covered by the Social
Security Administration or Railroad Retirement Board;
I file for social security benefits on any person's account;
Benefits I receive directly from tlie Social Security Administration are adjusted for a
RRB Form AA-lcert (xx-xx)

32948 64790 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0002

reason other than normal cost-01-living increases;
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 orgal-~ized(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;
I receive a settlement with credit for railroad service as "pay-for-time-lost" for
months after 8/24/2009;
My address changes even if my payments are sent to a financial institution;
My bank account changes;
I am confined to a jail, prison, penal institution, or correctional institution due to a
conviction for a criminal offense;
My spouse who is receiving a benefit dies or our marriage ends in divorce or
annulment;
A qualifying child marries or leaves my custody or residence.

Signat llre (First Name, Middle Initial, Last Name)

Date (MonthlDaylYear)

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 W i t n e s s

Signature of Witness

A d d r e s s (Street, City, State and ZIP Code)

Address(Street, City, State and ZIP Code)

L)

1-(

Daytime Telephone N u m b e r

Daytime Telephone N u m b e r

RRB Form AA-I cert (xx-xx)

.

32948 64790 22000 06051 32704

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