AA-1sum (proposed) Application Summary

PROPOSED (ALL POSSIBLE)

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

APPLICATION SUMMARY FOR (AN EMPLOYEE ANNUITY/
A DISABLED EMPLOYEE ANNUITY/MEDICARE)
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.
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.
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.

RRB Form AA-1sum (xx-xx)

81311 19200 22000 06051 32704

Page 1

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

Railroad Employment
7

You have a current connection with the railroad industry.

8

A current connection with the railroad industry is “deemed” because you:
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.
RRB Form AA-1sum (xx-xx)

81311 19200 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

Marriages
16 I have never been married.
17 I am currently married or separated.
18 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
RRB Form AA-1sum (xx-xx)

81311 19200 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

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.
32 I am receiving or expect to receive a pension or I received or expect to receive a lump-sum
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.

RRB Form AA-1sum (xx-xx)

81311 19200 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

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.
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.
RRB Form AA-1sum (xx-xx)

81311 19200 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

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
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 (annual exempt amount).
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.
RRB Form AA-1sum (xx-xx)

81311 19200 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

74 You are claiming premium surcharge relief based on coverage by an employer group health
plan.
(Printed if application is for Employee Annuity and employee is FRA or older.)
Your application for an Employee Annuity has been released and will be processed as quickly as
possible. If you do not receive notification about your application by __________ you should contact
the field office shown below.
You 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. 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 is for Employee Annuity and employee is under FRA.)
Your application for an Employee Annuity has been released and will be processed as quickly as
possible. If you do not receive notification about your application by __________ you should contact
the field office shown below.
You 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. 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 is for Disabled Employee Annuity.)
Your application for a Disability Annuity has been released and will be processed as quickly as
possible. If you do not receive notification about your application by __________ you should contact
the field office shown below.
You 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. 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 is for Medicare.)
Your application for Medicare has been released 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
RRB Form AA-1sum (xx-xx)

81311 19200 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

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
Railroad Work – If you return to work for a railroad or railroad labor organization or return to
work in any capacity in the railroad industry. (Printed if applicant is employee or disabled
employee.)
Railroad Work – If you change the date you will cease working for _________. On your
application you said that your last day of employment would be _______________.
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 or begin to receive a pension based on employment
not covered under the Social Security Act or Railroad Retirement Act.
Pension – If you receive a lump-sum payment or begin to receive a monthly pension from your
railroad employer or receive a distribution from a railroad sponsored 401(k) plan.
Other Benefits – If you begin to receive worker’s compensation or a public disability benefit.
Settlement – If you receive a settlement with credit for railroad service as “pay-for-time-lost” for
months after _________________.
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.
Employment – If you receive anything of value in lieu of salary or wages for any work that you
perform.
Earnings – If you work for any employer or perform any self-employment work.
Earnings – If your earnings change.
You told us you expect your total nonrailroad earnings for (current year) will be $________.
You told us you expect your total nonrailroad earnings for (current year) will be less than
$________.
You are earning more than $______.
You are not earning more than $_____.
Address – If your address changes, even if your payments are sent to a financial organization.
(Printed on employee and disabled employee applications.)
Address – If your address changes. (Printed if application type is Medicare only.)
RRB Form AA-1sum (xx-xx)

81311 19200 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

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.
Death or Disability – Your representative should notify the RRB immediately if you die or
become unable to handle your own benefits.
Spouse – If your spouse who is receiving a benefit dies or your marriage ends in divorce or
annulment.
Child – If a qualifying child marries or leaves your custody or residence.
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.
(Printed if application is for an employee or disabled employee annuity and applicant 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-1sum (xx-xx)

81311 19200 22000 06051 32704

Page 9