Form AA-4 (01-08) AA-4 (01-08) Self-Employment and Substantial Service Questionnaire

Ct41ven t

FORM ApPROVED

OMB No 3220-0138

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

SELF-EMPLOYMENT AND

SUBSTANTIAL SERVICE

QUESTIONNAIRE

Paperwork Reduction Act/Privacy Act Notices
The Railroad Retirement Board (RRB) is authorized to collect
the following requested information under Section 7(b)(6) of
the Railroad Retirement Act (RRA). This information is needed
to determine whether your self-employment will affect your rail­
road retirement benefits under the RRA. You are not required
to provide the information requested by this form. However,
your failure to provide us with the requested information may
result in our being unable to pay you any benefits.
The information you provide may be disclosed for purposes
of verification to the employer(s) named in item 8. A complete
listing of the persons, organizations and agencies to which
the information you give us may be released is available at
any office of the RRB.

We estimate this form takes between 40 and 70 minutes per
response, including the time for reviewing the instructions,
getting the needed data, and reviewing the completed form.
Federal agencies may not conduct or sponsor, and respon­
dents are not required to respond to a collection of informa­
tion unless it displays a valid OMB number. If you wish, send
any comments regarding the accuracy of our estimate or any
other aspects of this form including suggestions for improv­
ing the completion time, to the Chief of Information
Resources Management, Railroad Retirement Board, 844
North Rush Street, Chicago, Illinois 60611-2092.

SECTION 1-GENERAL INSTRUCTIONS
Always complete Sections 1-3 and Sections 5-7 of this form. Complete Section 4, as applicable, as explained in the instruc­
tions at the beginning of that section. Print all answers in ink or use a typewriter. If you are completing this form on behalf of
someone else, you must answer each question as it applies to that person. If you need more space than is provided to answer
a question, use Section 6 for this purpose. If you do not know the answer to a question, print "unknown" in the space provided
for the answer. When entering dates, always use numbers. Also, be sure there is one number in each box. For example, you
would enter June 6, 2007, as:

MONTH

DAY

YEAR

016 016 2101017
SECTION 2-INFORMATION THAt IDENTIFIES

You

Look over the information entered by the RRB for Items 1, 2 and 3 to be sure it is correct. If it is correct,
go to Item 4. If the information is not correct, line it out and enter the correct information.
1. RAILROAD RETIREMENT BOARD CLAIM NUMBER
2. RAILROAD EMPLOYEE'S SOCIAL SECURITY NUMBER

z

~

3. RAILROAD EMPLOYEE'S NAME

0--------------------------------------------------------------------------------------------­
~ 4. YOUR NAME
==
~---------------------------------------------------------------------------------------------

oIL
Z

If you are also completing Form AA-1, Application for Employee Annuity or Form AA-3, Application for
Spouse/Divorced Spouse Annuity, go to Item 7. Otherwise complete Items 5 and 6.

~---------------------------------------------------------------------------------------------

z

s:

IL

5. MAILING ADDRESS

~

STREET ADDRESS

~

CITY AND STATE

~

ZIP CODE

~

i=

ifi

£!

...

6. DAYTIME TELEPHONE NUMBER (INCLUDE AREA CODE)

~

"D'
Form AA-4 (01-08) (DESTROY PRIOR EDITIONS)

SECTION 3-INFORMATION ABOUT YOUR SELF-EMPLOYMENT

..

7a

b

~

8a

~
~

w

Enter the name of your business.

Enter an "X" in the appropriate box to indicate your form of business.
Corporation
0 Sole Proprietorship
Partnership
0 Consultant
Other (Describe):

o
o
o

Enter an "X" in the appropriate box to indicate your job title.
DOwner/Partner
0 Project Managerffeam Leader
0 Sales Person
0 Officer of Corporation
0 Consultant/Independent Contractor 0 Minister
0 Other (Describe): _ _ _ _ _ _ _ _ _ _ _ _ __

~------------------------------------------------------------------------b
Describe the service you perform and the skill level required.

c

Enter the name(s) and addressees) of the persons or organizations for whom you perform this service. (As used
in this questionnaire, "person" means individual, organization, or company.)

... ---------------------------------------------------------------------------..

9a

b

Are you a former employee of one or more
of the person( s) listed in Item Bc?

DYes - Go to Item 9b

o

No - Go to Item 11

Listthe name(s) of that employer(s).

w

()

~

w

~----------------------------------------------------------------------

ffi

~

10a Is the service you perform the same as the

DYes - Go to Item 11

service you performed as an employee?

o No - Go to Item 1Gb
ti. -------------------------------------------------------------­
b Explain how your current service differs from the service you performed as an employee.

Form AA-4 (01-08)

Page 2

T

11

Where do you perform your service (i.e., home, your own office, premises of the "person" shown in Item 8c)?

12

Enter an "X" in the appropriate box:

DYes

Do you advertise your services?

o

Enter the date you began performing
your service.

I MO~TH I

Are your services scheduled to end?

DYes - Go to Item 14b

w

0

~

w

CI)

IL

0

W

0

::5

a..

...
T
w
If)
i=
0::
W

>
C

«

No

...
T

13

14a

o
If)

w

b

!;;:

DAY

YEAR

No - Go to Item 14c

DAY

Enter the date your services are scheduled

YEAR

to end.

C

0w _________________________________________________________________________________________

~

w

c

Describe the agreement you have concerning the length of your service.

CI)

... ----------------------------------------------------------------------------------------T

DYes - Go to Item 16a

1Sa

~

b

Do you determine your own work hours,?

o

No - Go to Item 15b

Who determines your work hours?

::J

o

J:

w

o

~

w

CI)

Page 3

Form AA-4 (01-08)

DYes - Go to Item 16b
16a

o

Is your work activity supervised?

No - Go to Item 17

b Describe the extent to which you are supervised.

c

Provide the name and title of the person who supervises you.

z

o
~-------------------------------------------------------------------------------------

6:w
a..

::l

DYes - Go to Item 17b
17a

In your work activity do you supervise people?

o

o

b

Explain why you supervise them.

c

Describe their duties.

No - Go to Section 4

SECTION 4-INFORMATION ABOUT SUBSTANTIAL SERVICE

Only complete Items 18 through 20 (and Item 21 if your RRB annuity began before this year) if you are
claiming that you did not perform substantial service in self-employment for one or more months in that
year. Otherwise, leave these items blank and go to Section 5. (Note: This is the only section on this
form that may be left blank, as applicable.)
T

....z

18

w

~

~
..i5

•

19

$

Enter the approximate value of the business and
the percent of the business that you own.

)10

%

Enter the amount of your earnings from the business
that would continue based solely on the capital you
have invested in it without any service performed by you .

Form AA·4 (01·08)

Page 4

)10

$

T

20

w

Enter a monthly breakdown of
the amount of time you spent
in this employment this year. If
regular business hours varied
during certain months of the
year, state the reason for the
variance(s) (i.e., vacation, sick­
ness, etc.) in Section 6.

JAN

FEB

MAR

APR

MAY

JUNE

JULY

AUG

NOV

DEC

0

~

w

t/)

...J
~

j:::

z
~
II)

21

III
::J
t/)

Enter a monthly breakdown of
the amount of time you spent
in this employment last year. If
regular business hours varied
during certain months of the
year, state the reason for the
variance(s) (i.e., vacation, sick­
ness, etc.) in Section 6.

A
-----,r------------------------L------------~------------~--------------L--------------

T

SECTION 5-INFORMATION ABOUT YOUR EARNINGS

22

Enter a monthly breakdown of
your net earnings after deduc­

tion of allowable business

expenses under each month of r-------------+--------------+--------------t-------------­

this employment performed

this year.

APR
Enter a monthly breakdown of
FEB
JAN
MAR
your net earnings after deduc­

tion of allowable business

expenses under each month of r - - - - - - - - - - + - - - - - - - - + - - - - - - - - t - - - - - - - ­

AUG
MAY
JUNE
JULY

this employment performed
last year.

SEPT
A
T

___

-,~

24a

"

OCT

_ _ _ _ _ _ _ _ _ _ __ L_ _ _ _ _ _

~

NOV

_______

Are the payments you receive reported to the
Internal Revenue Service (IRS) by the person(s)
for whom you perform the services?

~

______

DEC

~

_ _ _ _ _ __

DYes - Go to Item 24b

o

No - Go to Item 25

~--~------------------------------------------

~

b

How are the payments reported to the IRS (i.e., as wages, non-employee compensation, etc.)?

w

==
o
o

~

Page 5

Form AA-4 (01-08)

0 Yes _ Go to Item 26
ffi
0 No - Go to Item 25b
a---------------------------------------------------------------------------------­
25a

!Z

Do you pay self-employment tax based on the income
received for the services you provide?

,.

b State the reason you do not pay self-employment taxes.

w

§
Q..

:is

W
U.

..J
W
tJ)

A __________________________________________________________________________________
26a Do you participate in a fringe benefit program
(Le., group medical insurance) of the person
named in Item 8c?

T

DYes - Go to Item 26b

o

No - Go to Item 27

b Describe the fringe benefits.
rJ)

l­

ii:
w
z

w
w
oz

m
i2

LL

A

T

---------------------------------------------------------------------------27a Is there a written contract in accordance with
which you perform your services?

DYes - Read 'Note' then
Go to Item 28

o

No - Go to Item 27b

Note: If answered "Yes, " you must submit a copy of the contract.

b Describe the verbal agreement.

I-

g
z

o

o

A _______________________________________________________________________________
T

28

Enter an "X" in the appropriate box:
Do you risk personal financial loss in your business?

A

DYes

o

No

---------------------------------------------------------------------------Form AA-4 (01-08)
Page 6

29a Do you receive money for your services?
)II

I­
Z

b Indicate your pay schedule, then go to Item 29d.

)II

w

0
0

0
0

Yes - Go to Item 29b
No - Go to Item 29c

Weekly

OBi-Weekly

0

Monthly

Other (Describe):

~----c---D-e-sc-r-ib-e-t-he--pa--ym--e-nt-o-r-r-e-im-b-u-r-se-m--en-t-y-o-u-r-e-ce-i-ve--ro-r-y-o-u-r-se-rv--ic-e-s-.-----------------------------

£1.
II.

o

w
a::

::)

z~ _____________________________________________________________________________________
d List any expenses you have that are not reimbursed.

SECTION 6-REMARKS

This section is to be used for the continuation of answers to other items. Be sure to include the item number
at the beginning of the answer you wish to continue. You may also use this section to enter any additional
information that you feel may be important to include.
y

30

Page 7

Form AA·4 (01-08)

SECTION

7-CERTIFICATION

31 I certify that all the information I have provided in completing this form is true to the best of my knowledge. I
know that if I have made a false or fraudulent statement on this form or if my refusal to provide this information
reflects a fraudulent intent to obtain benefits not authorized by law, I am committing a crime which is punishable
under Federal law by fine or imprisonment or both.

z

o

!i
(.)

SIGNATURE
(First Name, Middle
Initial, Last Name)

ii:

~
w

(.)

MONTH

DAY

YEAR

DATE

... ----------------------------------------------------------------------------------

T

32 If this certification is signed by mark ("X") in Item 31, two witnesses who know the person signing must sign
below, giving their full addresses and daytime telephone numbers.

a. Signature of Witness

Address (Number and Street)

City, State, ZIP Code

13

m
w
z

~------------------------------------------~--~~--~~--~~--~~--~~
:>
b. Signature of Witness

Address (Number and Street)

City, State, ZIP Code

MAIL THIS QUESTIONNAIRE TO THE ADDRESS SHOWN BELOW. MOST RAILROAD RETIREMENT BOARD
OFFICES ARE OPEN TO THE PUBLIC FROM 9:00 AM THROUGH 3:30 PM MONDAY THROUGH FRIDAY.

REFER ANY QUESTIONS TO: __~______'----_________________________

Form AA-4 (01-08)

Page 8