AA-1cert (proposed Application Summary and Certification

United States of America
Railroad Retirement Board

PROPOSED (COMPLETED)

Form Approved
OMB 3220-0002

APPLICATION SUMMARY and CERTIFICATION
RRB Claim Number
Name
Social Security Number

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

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 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
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 six 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, railroad labor organization or other employer in
the railroad industry.
Railroad Name
Date Last Worked
Date Rights Relinquished
Union Pacific Railroad
09/30/2011
09/30/2011

Name and Address

Lance Carter
215 Backstreet Market
Marathon Fl 02202

Daytime Telephone Number

219-201-8552

Date of Birth

08/28/1946

Type of Application Filed

Employee Annuity

I am applying for a benefit based on my age and railroad service
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-1cert (xx-xx)

81311 19200 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0002

Marriages
I am currently married or separated.
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 in the next three months 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 or lump-sum payment from Union Pacific Railroad.
Miscellaneous Information
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
employer.
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.
Earnings Information
In 2012, I expect my total nonrailroad earnings will be less than $14,640.
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.
RRB Form AA-1cert (xx-xx)

81311 19200 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0002

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

Application for an Employee Annuity - Certification
RR Claim Number
Name
Social Security Number

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

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 which is punishable under Federal law, which may include
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-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.
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.
I receive a lump-sum or begin to receive a pension based on earnings that are not
covered by the Social Security Act or 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 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
RRB Form AA-1cert (xx-xx)

81311 19200 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0002

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 receive a settlement with credit for railroad service as “pay-for-time-lost” for
months after 9/30/2012.
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

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