AA-1cert (proposed Application Summary and Certification

PROPOSED (ALL POSSIBLE)

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0002

APPLICATION SUMMARY and CERTIFICATION
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/a Disabled Employee 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.
Military Service
1

I was not in active military service after September 7, 1939.

2

I was in active military service after September 7, 1939.

Recent Employment
3

I did not work for an employer outside the railroad industry in the last six months or since
leaving the railroad industry.

4

I worked for the following employers outside the railroad industry in the last six months or
since leaving the railroad industry.
(Company Name)
(Company Name)
(Company Name)

5

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

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

6

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

I was self-employed during the last 12 months.

Railroad Employment
7

You have a current connection with the railroad industry.

8

A current connection with the railroad industry is “deemed” because you:

RRB Form AA-1cert (xx-xx)

81311 19200 22000 06051 32704

Page 1

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0002

1 Have at least 25 years of railroad service, and
2 “Involuntarily and without fault” stopped working for the railroad on or after October 1,
1975 and was never called back to work for the railroad employer, and
3 Did not decline an offer from a railroad employer to return to a job in the same “class
or craft” as the last railroad job.
9

You do not have a current connection with the railroad industry.

10

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

Name and Address
Daytime Telephone Number
Date of Birth
Type of Application Filed

(Employee Annuity /Disabled Employee Annuity/
Medicare)

Application Filing Date
11

I am applying for a benefit based on my age and railroad service.

12

I am applying for a benefit based on being disabled.

13

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

14

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.

15

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

Marriages
16

I have never been married.

17

I am currently married or separated.

RRB Form AA-1cert (xx-xx)

81311 19200 22000 06051 32704

Page 2

United States of America
Railroad Retirement Board

18

Form Approved
OMB 3220-0002

I was previously married.

Family
19

I have a child or children who are unmarried and under age 18.

20

I have a child or children who are unmarried and age 18 through 19 and attending
elementary or secondary school full-time.

21

I have a child or children who are unmarried and age 18 or older with a continuing
disability that began before age 22 and prevents any type of employment.

22

I do not have unmarried qualifying children.

Other Government Benefits
23

I am currently receiving a social security benefit.

24

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

25

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

26

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

27

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

28

I am not receiving a social security benefit.

29

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

30

In the past month I have not filed nor do I plan to file in the next three months for Railroad
Retirement benefits on any other account number.

31

I am currently receiving a railroad retirement annuity on another account number.

RRB Form AA-1cert (xx-xx)

81311 19200 22000 06051 32704

Page 3

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0002

32

I am receiving or expect to receive a pension or I received or expect to receive a lumpsum payment instead of a monthly pension based on my earnings after 1956 from an
employer not covered by Social Security or Railroad Retirement.

33

I am not receiving nor do I expect to receive a pension or lump-sum payment based on
my earnings after 1956 from an employer not covered by Social Security or Railroad
Retirement.

Other Benefits
34

I am receiving a railroad pension from ______________.

35

I received a lump-sum payment from _________________.

36

I expect to receive a railroad pension or lump-sum payment from ________________.

37

I am not receiving nor do I expect to receive a pension or lump-sum payment from a
current or former railroad employer.

38

I have received or I expect to receive worker’s compensation benefits.

39

I have not received nor do I expect to receive worker’s compensation benefits.

40

I have received or I expect to receive disability benefits under a Federal, state or local
government plan or law.

41

I have not received nor do I expect to receive disability benefits under a Federal, state or
local government plan or law.

Miscellaneous Information
42

The RRB has not been furnished with a court order to enforce my child support or alimony
obligation.

43

The RRB has been furnished with a court order to enforce my child support or alimony
obligation.

44

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.

RRB Form AA-1cert (xx-xx)

81311 19200 22000 06051 32704

Page 4

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0002

45

The RRB has 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.

46

I have not received nor do I expect to receive pay for time lost from my last railroad
employer.

47

I have received pay for time lost from my last railroad employer.

48

I expect to receive pay for time lost from my last railroad employer.

49

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 day
I last worked.

50

I have received sick pay under a wage continuation plan, established through company
policy or a labor agreement, for a period after the actual day I last worked.

51

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 day I last worked.

Earnings Information
52

In (prior year), my total nonrailroad earnings were (actual earnings).

53

In (prior year), my nonrailroad earnings were less than (annual exempt amount).

54

In (prior year), I earned more than (monthly exempt amount) in each month.

55

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

56

In (current year), I expect my total nonrailroad earnings will be (estimated earnings).

57

In (current year), I expect my total nonrailroad earnings will be less than (annual exempt
amount).

58

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

59

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

RRB Form AA-1cert (xx-xx)

81311 19200 22000 06051 32704

Page 5

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0002

60

In (next year), I expect my total nonrailroad earnings will be (estimated earnings).

61

In (next year), I expect my total nonrailroad earnings will be less than (estimated
earnings).

Criminal Offense Information
62

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.

63

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

Beginning Dates and Filing Dates
64

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

65

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

66

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

67

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

68

I do not want this application to protect my filing date for Social Security benefits.

Medicare
69

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

70

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

71

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

72

My annuity will begin before I am age 63 and I am totally disabled for work.

73

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

74

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

RRB Form AA-1cert (xx-xx)

81311 19200 22000 06051 32704

Page 6

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0002

Application for (an Employee Annuity/a Disabled Employee Annuity/Medicare) Certification
RR Claim Number
Name
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.
(Printed if application is for Employee Annuity and employee is FRA or older.)
I have received and reviewed the booklets RB-1, Age and Service Employee 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 is for Employee Annuity and employee is under FRA.)
I have received and reviewed the booklets RB-1, Age and Service Employee 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.
(Printed if application is for Disabled Employee Annuity.)
I have received and reviewed the booklets RB-1, Age and Service Employee Annuity, RB-1d,
Employee Disability Benefits, 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.
I agree to immediately notify the RRB, if
I return to work for a railroad or railroad labor organization or return to work in any
capacity in the railroad industry.
RRB Form AA-1cert (xx-xx)

81311 19200 22000 06051 32704

Page 7

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0002

I receive a lump-sum or begin to receive a pension based on employment not covered
under the Social Security Act or the Railroad Retirement Act.
I file for social security benefits based 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 am filing in advance and my last date of employment changes.
I return to work for (print last nonrailroad employer).
I earn over the annual earnings exempt amount.
My expected earnings amount changes.
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.
I begin to receive worker’s compensation or a public disability benefit.
I receive a settlement with credit for railroad service as “pay-for-time-lost” for months
after (print date railroad employment ended).
I receive a lump-sum payment, begin to receive a monthly pension from my railroad
employer, or receive a distribution from a railroad sponsored 401(k) plan.
My address changes.
My financial organization or the account number at my financial organization changes.
I am confined in a jail, prison, penal institution, or correctional facility 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.

_________________________________
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-1cert (xx-xx)

81311 19200 22000 06051 32704

Page 8