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pdfUnited States of America
Railroad Retirement Board
Form Approved
O.M.B. No. 3220-0031
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lnstructions on Internet
Do Not Write in This Space
Officially Filed
I
Office Number
Application for Lump-Sum
Death Payment and
Annuities Unpaid at Death
, ,
Approved
1........-.--......................-.............-..-........... l
Apicaon m
Date Coded
e
Coded by
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General lnstructions
Before you complete this application, be sure to read the booklet RB-21, Lump-Sum Death Payment, Residual LumpSum,
and Annuities Unpaid at Death, which explains informationyou will need to answer many of the questions in this application.
Please be sure to read the important notices on the inside covers of the RB-21 booklet. Type or print legibly in ink.
If you need more space than is provided to answer a question, use Section 8, Remarks, 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 6,2008 as:
MONTH
DAY
YEAR
0 6 016 2101018
Some items in this application will not apply to you so you will not need to answer them. Based on your answer to a
question, you may be told to skip to another item number, or even another section. Follow the instructions that tell you
to "Go to" another item. These are designed to save you time and help you move through the application form quickly,
filling in only necessary information. If no "Go to" instructions are given, answer the next item in order. Do not
skip any items unless directed to do so.
If you are completing this application on behalf of someone else, you must answer each question as it applies to the applicant
Identifying Information
Check the information entered by the Railroad Retirement Board (RRB) in Items 1 through 6 for accuracy.
b If the information is correct, go to Item 7.
b If the information is not correct, cross out the incorrect information and enter the correct information above it.
b If the information is missing, fill it in.
Employee 1
IdenSMon
Employee's Name
2 Employee's Social Security Number
Applicant 4
Identification
3 Employee's Railroad Retirement Claim Number (include Prefix)
Applicant's Name NOTE: If representative of funeral home, enter funeral home's name, representative's name, and representative's title.
5a Mailing Address NOTE: If representative of funeral home, enter funeral home address.
5 b City and State
5 c ZIP Code
6
7 Applicant's social security number. If none, enter "NONE."
Daytime Telephone Number (include area code)
5d County
NOTE: Do not complete if you are the funeral home director.
Form AA-21 (1 1-08) Destroy Prior Editions
Information About The Employee
If a railroad retirement survivor benefit was ~reviouslyreceived by someone.- go
- to ltem 8.
- to Section 5; otherwise go
Birth Date 8
Enter the employee's date of birth.
Residence 9
Enter the state (or country if other than
United States) which was the employee's
permanent home at the time of death.
Month
Year
Day
b
b
Please read the chapter, "Credit for Military Service," in the RB-21 booklet to find out how active military service is determined.
110 Enter an " X in the appropriate box:
The employee was in active military service after September 7. 1939.
I
('
,'
Disability
P-
a
Yes b Go to Note and Item II
No
b Gotolternl3
Note: If answered 'Yks,
" and proof of the employee's military service is not already in
our file, you may be requested to provide it We will notify you /icproofis needed.
11 Enter an 'X" in the appropriate box:
The employee had voluntary military service during the period
June 15,1948, through December 15,1950.
b
12 Enter an " X in the appropriate box:
The employee had nonrailroad earnings after leaving the
military service and before returning to the railroad.
b
O Yes b
0 No b
Go to ltem I 2
Go to Item I 3
Yes
a
No
If the employee died at 62 or older, go to Item 14.
--....-.--.....-----...........-.----..-.....------.------..--.-........-....---A............-..-.-----------.----..-..-...-...7----.--------13 Enter an " X in the appropriate box:
Yes
.
.
a
b
The employee was unable to work at the time of death because of an
illness or accident which occurred at least five months before death.
a
No
14 Regardless of whether the employee was retired at death, enter the name and address of each railroad or non-railroad
Recent
employ me^
employer for whom the employee performed any part-time or full-time work during the last three years. Enter the name
and address of the most recent employer in 14a, the second in 14b, and so on. Enter the date each job began and
ended. If you need additional space, continue in Section 8.
Name and Address of Employer
a Name
Benan
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Address
Month
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Year
Ended
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Month
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Year
City, State, and ZIP Code
b Name
Began
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Address
Month
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Year
I
Ended
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Month
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Year
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City, State, and ZIP Code
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c Name
Address
Began
Month
I
Year
I
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Ended
Month
City .State, and ZIP Code
15 Enter an 'X" in the appropriate box:
)Pn The employee was self-employed during any
of the last three calendar years.
b
16 Enter an " X in the appropriate box:
The employee's net earnings from self-employment were
more than $400 in any of the last three calendar years.
Form AA-21 (11-08)
Page 2
b
Yes b- Go to ltem I 6
O
No
O
Yes b- Go to ltem I 7
No
b- Go to ltem I 8
b- Go to ltem I 8
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Year
I
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Self17 Enter an "X" in the appropriate box(es) to show the year
Employment
or years in which the employee's net earnings from
(Continued)
b-
Railroad
18 Enter an "X" in the appropriate box:
Employment
The employee was alive on October 1, 1981,
b-
O
self-employment were more than $400.
AND had at least 25 years of railroad service.
This year
Last year
Year before last
Yes
a
No
b
b
Go to Note and ltem 19
Go toltem 21
(~ote: Please read the chapter, "Requirements the Employee Must Have Met,"
in the RB-21 booklet to find out what special conditions may apply if the employee
was alive on October I, 1981, and had at least 25 years of railroad service.
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19 Enter an " X in the appropriate box:
The employee "involuntarily and without fault":
,
stopped working for his or her last railroad
employer on or after October I,1975, or
b-
was on furlouah. leave of absence status. or absent
because of inrury on October I,1975, and was never
called back to work for that employer.
I
20 Enter an "X" in the appropriate box:
The employee declined an offer from a railroad employer
to return to a job in the same "class or craft" as his or her
last railroad job.
b
b
Go to ltem 20
Go to ltem 21
O No
b
b
O Yes
O No
b
b
Go to ltem 22
Yes
O
O No
b-
Emp]o~ee's21 Enter an "X" in the appropriate box:
Mamages
Was the employee ever married?
Yes
Go to ltem 21
Go to Note and ltem 21
Go to Section 5
22 Enter the requested information for each of the employee's marriages. Enter the most recent marriage in 22a, the second
most recent in 22b, and so on. If the employee was married only once, enter the information in 22a, and go to ltem 23.
Name of Employee's
Wife or Husband
(if wife, include
maiden name)
I
City and State
Married
(Country, if other
than U.S.)
Date
Manied
How Marriage
Ended
Answer if Marriage Ended for Reason
Other than Employee's Death
City and State
Marriage Ended
Date Mam'age
(Countrv, if other
a
1
Month Day
I Year
=T:
Month Day
Year
23 Enter an 'X' in the appropriate box:
At least one of the employee's marriages lasted for ten years
and ended in divorce.
(
b-
O Yes b Go to Note and ltem 24
O No b Go to Section 4
Note: If more than one marriage fits this description, use Section 8 to answer
Items 24-28 for each additional marriage.
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Page 3
Form AA-21 (11-08)
Employee's 24 Enter an 'X" in the appropriate box:
Marriages
The divorced spouse was alive in the month the employee died.
(Continued)
b-
Yes b- Go to ltem 25
O
No b- Go to Section 4
Month
b-
25 Divorced spouse's date of birth.
a
a
26 a Enter an 'X" in the appropriate box:
The divorced spouse has remarried.
27 a Enter an 'X" in the appropriate box:
The marriage has ended.
Month
b-
a
0
Day
Year
-
Yes b- Go to ltem 27b
No b- Go to Item 28
Month
b-
b Date the marriage ended.
Year
Yes b- Go to Item 26b
N o b- Go to Item 28
b-
b Divorced spouse's date of remarriage.
Day
Day
Year
1 11
28 a Divorced spouse's name.
b Divorced spouse's social security number.
b-
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aI
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c Mailing Address
d City and State
g Daytime Telephone Number (include area code)
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28f County
28e ZIPCode
1
b- (
1
Information About The Widow(er)
a
Widow(er) 29 Enter an "X" in the appropriate box:
The employee was survived by a widow(er).
0
-
Widow(er)'s 30 Widow(er)'s date of birth.
Birthdate
Yes b- Go to ltem 30
N o b- Go to Section 5
Month
b-
a
a
Widow(er)'s 31' Enter an "X" in the appropriate box:
Disabi'i"
The widow(er) was age 50 - 59 in the month the employee died.
Support
b-
33 Enter an "X" in the appropriate box:
The widow(er) is still alive.
b-
34 Enter an "X" in the appropriate box:
The employee and the widow(er) were living together
when the employee died.
b-
35 Enter the date the widow(er) and the employee stopped
living together.
b-
..
Form AA-21 (11-08)
Page 4
- -
O Yes
a
NO
O Yes b- Go to ltem 34
O IVo b- Go to Section 5
0
Yes b- Go to ltem 39
N o b- Go to ltem 35
Month
36 Enter the reason(s) the widow(er) and the employee stopped living together.
Year
Yes b- Go to Item 32
No IF Go to ltem 33
-
32 Enter an 'X" in the appropriate box:
In the month the employee died, the widow(er) was unable to
work due to an accident or illness.
Day
Day
Year
Support
37 Enter an 'X" in the appropriate box:
(Continued;
'
Nameat
Birth
Yes b Go to Item 39
The employee was making regular contributions to the
widow(er)'s support when the employee died. (Consider the
following as contributions to support: money, food, clothes,
paying bills, providing rent-free housing.)
No
38 Enter an 'X' in the appropriate box:
The employee was under a court order to contributeto the
widaw(er)'s support. (Note: Answer 'Yes" if there was a court
order, even if the employee was not obeying it.)
b
39 Enter an " X in the appropriate box:
I am the employee's widow(er).
b
40 Enter your name at birth.
b
Widow(er)'s 41 Enter an " X in the appropriate box:
Marriages
I am now, or was previously, married to someone other
b Go to ltem 38
Yes
O
No
Yes b Go to ltem 40
No b Go to Section 5
Yes b Go to ltem 42
b
No b Go to Section 5
than the employee.
42 Enter the requested information for each of your marriages to someone other than the employee.
Enter your spouse's name at birth and social security number (SSN). If the SSN is unknown, provide the date and place of
birth of the spouse and the name at birth of both parents of the spouse in Section 8.
Enter the most recent marriage in 42a the second most recent in 42b, and so on. ,
Social Security Number
a Spouse's Name
Date Married
Month
Day
City and State
Manied
(Country, if other
than U.S.)
Year
How Marriage
Ended
(check one)
D
Spouse's Death Month
D
Annulment
a Divorce
Month
Day
City & State
Married
(Country, if other
than U.S.)
How Marriage
Ended
(check one)
D
Year
a
a
Month
Day
Year
Year
Date Marriage
Ended
Spouse's Death Month Day
D'lvorce
Annulment
City & State
Marriage Ended
(Country, if other
than US.)
Year
Social Security Number
c Spouse's Name
Date Married
Day
City and State
Marriage Ended
(Country, if other
than U.S.)
Social Security Number
b Spouse's Name
Date Married
Date Marriage
Ended
City & State
Married
(Country, if other
than U.S.)
How Marriage
Ended
(check one)
D
a
a
Date Marriage
Ended
Spouse's Death Month Day
D'lvorce
Annulment
Page 5
City & State
Marriage Ended
(Country, if other
than U.S.)
Year
Form AA-21 (11-08)
Information About the Employee's Family
Child's
Annuity
43 Enter an 'X' in the appropriate box:
There is a "child," as defined in Section I I , who may
be eligible for an annuity.
(
a Yes ba No b-
b
Go to ltem 44
Go to ltem 45
N
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instances) grandchild of the deceased employee who, in the month the employee died, was:
UNDER age 18, or
Age 18-19 AND attending high school full time, or
ANYAGE as long as the "child was totally and permanently disabled
BEFORE the child obtained age 22.
For a complete explanation of the circumstances in which a "child may be eligible for
44 Provide the information requested below for the child(ren) referred to in ltem 43.
Child's Full Name
Legal Relationship
(Check One)
0 Natural
0 Stepchild
0 Legally Adopted
0 Equitably Adopted
0 Deemed
a
Address and Telephone Number
Address
Telephone Number (include area code)
a Grandchild
a Stepgrandchild
Child's Full Name
Legal Relationship
(Check One)
a Natural
a Stepchild
a Legally Adopted
a EquitablyAdopted
a Deemed
0 Grandchild
a Stepgrandchild
b
Child's Full Name
Address
Telephone Number (include area code)
(
Address
Telephone Number (include area code)
(
b
46 Enter an " X in the appropriate box:
A child of the employee is expected to be born.
b
47 Enter month and year child is expected.
b
b
The employee was survived by a parent.
49 Enter an 'X" in the appropriate box:
The parent was dependent on the employee for
one-half support.
Form AA-21 ( I 1-08)
b
Page 6
1
Address and Telephone Number
45 Enter an "X" in the appropriate box:
The deceased employee was female.
Parent's 48 Enter an "X" in the appropriate box:
Annuity
1
Address and Telephone Number
Legal Relationship
(Check One)
a Natural
a Stepchild
a Legally Adopted
a EquitablyAdopted
a Deemed
a Grandchild
a Stepgrandchild
c
(
1
Yes b- Go to ltem 48
b- Go to Item 46
a No
a Yes
b- Go to ltem 47
No b- Go to Item 48
Month
a Yes
a No
b- Go to ltem 49
b- Go to Item 51
Yes b- Go to ltem 50
No b- Go to ltem 51
Year
Parent's
Annuity
50 Enter the requested information for each dependent parent of the employee.
a
Name of Parent
Date of
Birth
Month
Year
Address and Telephone Number
(
b
1
Name of Parent
Address and Telephone Number
(
1
Information 51 Enter an " X in the appropriate box:
About
Iam the employee's widow(er) and I was living with the
Applicant
b
52 Enter an " X in the appropriate box:
I am completing this application as a representative of a
funeral home.
b
53 Enter an "X" in the appropriate box:
I am the employee's natural child, legally adopted child,
equitably adopted child, deemed child, parent, grandchild,
brother, sister, half-brother or half-sister.
b
a Yes ba No ba Yes ba No ba Yes b-
employee when the employee died.
Go tosection 7
Go to ltem 52
Go tosection 7
Go to ltem 53
Go to ltem 54
No b- Go to Section 6
I
Children
54 Enter the requested information for any surviving child(ren) of the employee (except stepchildren) not listed in ltem 44.
-
Name of Child
(If none, enter "NONE)
Legal
(Check One)
-
Address and Telephone Number (include area code)
Natural
Legally Adopted
Equitably Adopted
Deemed
a Natural
a Legally Adopted
b
Equitably Adopted
Deemed
Natural
a Legally Adopted
a Equitably Adopted
0
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GrandChildren
Deemed
Note: I f any child is listed above, go to Section 6.
55 Enter the requested information about any surviving grandchild(ren) of the employee not identified in ltem 44
(except a stepgrandchild) no matter how old they are, what their marital status is, and regardless of whether the
employee was supporting them.
I
Name of Grandchild
(If none. enter “NONE)
I
Address and Telephone Number (include area mde)
I
Name at Birth
of Parents
Father
Mother
Father
Page 7
Form AA-21 (1 1-08)
Name of Grandchild
(If none, enter "NONE)
GrandChildren
(Continued)
Name at Birth
of Parents
Address and Telephone Number (include area code)
Father
Mother
Father
d
Mother
I
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Note: I f any child is listed in ltem 55, go to Section 6.
Brothers
and
Sisters
56 Enter the employee's surviving brothers, sisters, half brothers and half sisters. Do Not include stepbrothers or
stepsisters. If you need additional space, continue in Section 8.
I
Address and Telephone Number (include area code)
Name (If none, enter "NONE)
a
See Section 11 for additional instructions before answering questions in Section 6.
Funeral
Home
Expenses
57 Enter the total amount of funeral home expenses.
b
$
58 Enter the amount of funeral home expenses paid with
your own money.
(If none, check box.)
b-
$
None
59 Enter the amount of funeral home expenses paid with
the employee's money.
(If none, check box.)
b
$
O None
60 Enter the amount of funeral home expenses paid with
any other person's money.
(If none, check box.)
b-
$
O None
61 Enter the amount of funeral home expenses which are
still not paid.
(If none, check box.)
O None
If "None," go to Item 66
-
AEnmW
The RRB considers that a person has assumed responsibility for unpaid funeral home expenses if either the
d
person has paid some portion of the total funeral home expenses or there is an agreement between the person
Responsibih' and the funeral home about how the expenses will be paid.
62 Enter an "X" in the appropriate box:
I have assumed responsibilityfor the funeral home
expenses which are not paid.
63 Enter an "X" in the appropriate box:
Some other person or organization has assumed responsibility
for the funeral home expenses which are not paid.
Form AA-21 (11-08)
Page 8
a Yes
a No
b Go to Item 65
b Go to ltem 63
Yes b Go to Item 64
0 IVo b
Go to ltem 66
64 Enter the full name of the person or organization who assumed responsibility then go to Item 66.
Name
Telephone Number (include area code)
Address
1
(
65 If any of the funeral home expenses are unpaid, the lump-sum death payment (or a part of the lump-sum death
payment equal to the amount of the unpaid funeral home expenses) can only be paid to the funeral home.
However, before this payment can be made, you must authorize the RRB to make the payment.
I request the RRB to pay the lump-sum death payment to:
Name of funeral home
1
Address of funeral home
Teh
' one
Number (include area d e )
1
7,
r ~ o t eIf: there are unpaid funeral home expenses at more than one
funeral home, show the name, address, and telephone number of the
other funeral home(s) in Section 8.
[
Opening
66 Enter the total amount of the cost of opening
and Closir
and closing the grave not included in Item 57.
of Grave
b-
$
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IJ None
(If none, check box.)
If "None." ao to ltem 70
When answering Items 67-77, consider any money you received from a life insurance policy or other death
benefit as your own if you were named as the beneficiary for the policy or benefit. Also, consider money
from any bank account as your own if you were one of the joint owners of the account.
67 Enter the amount of the grave opening and closing
costs paid with your own money.
(If none, check box.)
b-
$
IJ None
68 Enter the amount of the grave opening and closing
costs paid with the employee's money.
(If none, check box.)
b-
$
IJ None
69 Enter the amount of the grave opening and closing
costs paid with any other person's money.
(If none, check box.)
Burial
Plot
70 Enter the total amount of the cost of the burial plot not
included in Item 57.
(If none, check box.)
IJ None
b-
$
IJ None
If "None," go to ltem 74
71 Enter the amount of the burial plot cost paid with your
own money.
(If none, check box.)
b-
$
IJ None
72 Enter the amount of the burial plot cost paid with the
employee's money.
(If none, check box.)
b-
$
IJ None
73 Enter the amount of the burial plot cost paid with any
other person's money.
(If none, check box.)
b-
$
IJ None
Page 9
Form AA-21 (11-08)
Other
74 Enter the amount of other burial expenses not
included in ltem 57.
Expenses
(If none, check box.)
b
Burial
I
$
Q None
If "None," go to Item 78
75 Enter the amount of other burial expenses paid
with your own money.
(If none, check box.)
b
$
Q None
76 Enter the amount of other burial expenses paid
with the employee's money.
(If none, check box.)
b
$
Q None
77 Enter the amount of other burial expenses paid
with any other person's money.
(If none, check box.)
b
$
Q None
Other
78 Enter an "X" in the appropriate box:
Federal
An application for a burial allowance has been, or will be,
Allowances
a Yes
a No
filed with the Department of Veterans Affairs or other
Federal agency.
b Go to ltem 79
b Go to Item 80
79 Enter the requested information about who the application for a burial allowance has been, or will be, filed with.
Agency
Amount
Name of Person Filing with Agency
a Department of Veteran Affairs
a Other Federal Agency (Specify)
$
Reimburse- 80 If you did not pay any of the burial expenses, go to ltem 82.
ment
When answering Items 80 and 81 DO NOT consider any money you received from a life insurance policy or
other death benefit if you received the money because you were named beneficiary for the policy or benefit.
DO NOT consider any money from any bank account if you were one of the joint owners of the account. Also,
DO NOT consider any money, goods, or property that you inherited from the employee under the provisions
of a valid will or applicable state law.
.-..-..-------..-----..
....-----..
.........-..-..-..-..
................--...
..--..
...........-..-..
...-..-.---.
...-.--.----.-------...--.
.----.-.-..
-....---.
..-..-- ----..
--------.
.........
Enter an " X in the appropriate box:
!J Yes b Go to Item 81
I have received, or I will receive, money or property
b
(real estate or other goods) to pay me back for the
No b Gotoltem82
burial expenses I paid.
a
8 1 Enter the requested information for each source of payment to you.
1
Estate
I
Source of Money or Property
82 Enter an " X in the appropriate box:
A court appointed administrator or executor has been
appointed. (Answer "No" if someone has been named in
the employee's will only.)
Form AA-21 (11-08)
Page 10
Date Received or Expected
b
I
Amount or Value
!J Yes b Go to ltem 83
!J No b Go to Item 84
.
Estate
83 Enter the requested information about the administrator or executor.
(Continued)
a
Name
(If applicant, enter "SELF" and go to ltem 84)
I
b Address
I
c
b
b
Telephone Number (include area code)
1
(
Other
84 Answer only if any other person or organization paid any of the burial expenses.
Payers of .---..-...
------.---..
....-.-.-..
...-------------..-..
..-.-.......----..
...-.-...-..-..
.....-..-..
...-..-.------.
..----..-...
.....-..-..--.-...
......--.----.
..-.....--.-------------------- -.-. Burial
Expenses
Enter the requested information for each source who paid expenses.
Name, Address, and Telephone Number
of Person or Organization
Type of Burial Expenses
(Check One)
I
Amount
Q Funeral Home
Q Grave OpeninglClosing
Q Burial Plot
$
a Other
a Funeral Home
a Grave OpeninglClosing
Q Bulial Plot
a Other
0
$
Funeral Home
a Grave OpeninglClosing
a Burial Plot
$
Q Other
Funeral Home
Q Grave OpeninglClosing
Q Burial Plot
$
Q Other
I
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Direct Deposit
Do not complete this section if your account is at a foreign bank.
Direct
Deposit
Benefits are normally paid by Direct Deposit to your bank, savings and loan, credit union, or other financial institution.
To provide the information we need to correctly deposit your payments, attach a voided personal check and go to
Section 8, or call your financial institution for the information you need to complete Items 85-89. If you do not have a
bank account, or receiving your payments by Direct Deposit would cause you a hardship, go to ltem 90.
1
b
85 Print the name of your financial institution.
86 Print the telephone number (including area
code) for your financial institution.
87 Print the routing transit number
of your financial institution.
88 Print your account number.
b
b
a Checking
a Savings
89 Enter an " X in the appropriate box:
Type of account for the above account number.
Go to Section 8
90 Check this box if you do not have a checking or savings
account, or if Direct Deposit would cause you a hardship.
Page 11
b
0
Form AA-21 (11-08)
Remarks
Remarks
91 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.
Form AA-21 (11-08)
Page I2
Certification
Certification 92 1 know that if I make a false or fraudulent statement in order to receive benefits from the Railroad Retirement Board,
(RRB), I am committing a crime which is punishable under Federal law.
If I receive the lump-sum death payment because I paid the employee's burial expenses, I also agree not to request
or accept reimbursement from another party for that part of the burial expenses for which I am reimbursed by the
lump-sum death payment.
I
I have received the appropriate application booklet.
I certify that the information I gave to the RRB on this application is true to the best of my knowledge.
Signature
(First Name, Middle Initial,
Last Name)
Date
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93 If this application is signed by mark ('X") in Item 92, 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)
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I
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City. State, and ZIP Code
b Daytime Telephone Number (include area mde)
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1
(
1
Signature of Witness
Address (Number and Street)
City, State, and ZIP Code
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Daytime Telephone Number (include area mde)
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Before you return your application, check to make sure that:
Every question that applies to you has been answered.
You have entered "unknown" in any answer space for which you were unable to answer a question.
You have signed and dated the application.
You have included all the needed proofs listed in the letter you received with this application.
When you received your application, you should also have received a pre-addressed return envelope. If you do not have
this envelope, you can use any envelope as long as it is addressed to the RRB shown on the last page of this
application. No matter which envelope you use, you must put the correct postage on the envelope. Be careful to provide
enough postage, because your application and the accompanying forms may weigh more than a standard letter. The
U.S. Postal Sewice will not deliver your application unless it has the correct postage.
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Make one final check before you seal the envelope to ensure that the following are enclosed:
Needed proofs
The application itself
Additional forms y o u were asked t o complete
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Note: A receipt for your application will be sent to you after the RRB receives your completed and signed
application. When you receive the receipt, you will know that the RRB has received your application and has
started the work needed to determine if you are entitled to benefits. If you do not receive your receipt within a
month after you filed this application, please contact us so we can find out what is causing the delay.
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Page 13
Form AA-21 (11-08)
This section contains m&e detailed instructions or explanations for a few of the items on the application form. Whenever the
instructions on the Form AA-21 refer you to Section 11 you should read this section for the particular question or section
before you complete that part of the application. This section can be detached from the Form AA-21 packet before the
application is returned to the Railroad Retirement Board (RRB).
The RRB may be able to pay an annuity to a child of a deceased railroad employee if the child meets certain requirements.
When we use the word "child" we are including all of the following categories of children:
Natural child.
Stepchild.
Legally adopted child.
Equitably adopted child (that is, the employee intended to adopt the child but a legal adoption was not complete before
the employee died).
Deemed child (that is, a child who is born during an invalid marriage).
Grandchild.
Stepgrandchild.
In order to be considered for an annuity, the child must be unmarried. In addition, the child must be:
under age 18; or
age 18 or older and became disabled before age 22 and the disability is not expected to ever go away; or
age 18-19 and is attending high school full time.
If the child is the employee's stepchild, the employee must have been providing at least one-half support. If the child is the
employee's grandchild or stepgrandchild, the employee must have been providing at least one-half of the child's support and
either the child's own parents were dead or disabled or the child was legally adopted by the employee's widow or widower.
Even if there are no children who meet all these requirements right now, a child's annuity may be able to be paid if any child
met all the requirements in the month the employee died or later or, if the employee died more than six months ago, if any
child met these requirements anytime in the last six months.
If there is any child who meets these requirements, put an " X in the "YES" box. In addition, you, some other adult acting
for the child, or the child should contact the RRB as soon as possible and request information about childrens' annuities.
Section 6 (Items 57-84)
Section 6: Information About Burial Expenses requires various information about the types of burial expenses which have
resulted from the employee's death and about the people who paid these expenses and the money which was used to pay the
expenses. Please refer to the following definitions when completing Items !3-84.
Burial Expenses
Burial expenses include any expenses which arose in connection with the burial or cremation of the employee's body. These
include the burial plot, casket, clothing, cremation, death certificates, embalming, flowers, hearse and car for funeral
procession, minister, monument, newspaper notice, niche, opening and closing of grave, permits, perpetual care of grave,
preparation of body for burial, religious services, telegrams, telephone calls, transportation of the body, traveling expenses of
the person escorting the corpse or completing burial arrangements, and so on.
Funeral Expenses
Funeral expenses include any of the above burial expenses if the expense is incurred by or through the funeral home. In
other words, any burial expense which is included in the funeral home's charges is considered a funeral expense.
Burial Plot Cost
The cost of the burial plot is the value of the plot at the time the employee is buried, even if the plot was purchased
before the employee's death. If the plot in which the employee is buried is part of a multiplot plot, only the portion of
the value of the plot which corresponds to the portion of the plot in which the employee is buried is considered the
burial plot cost.
Continued to Page 15
Form AA-21 (11-08)
Page 14
Continued from Page 14
Other Burial Expenses
Any burial expense which is not included in the funeral home's charges, is not the cost of opening or closing of the grave
and is not the burial plot cost can be included in the total other burial expenses.
Your Own Money
You should consider that you paid expenses with your own money if the money used to pay the expenses was your own
personal funds, money in a bank account if it was a joint account owned by you and the employee, money from an insurance
policy if you were the beneficiary of the policy, or death benefits from a fraternal association, union or employer if you were
named beneficiary of the benefits. If you are applying as the representative of an institution, organization, or association you
should treat the money paid by the institution, organization, or association that you are representing as your own money.
The Employee's Money
No matter who makes the actual payment, consider that burial expenses were paid with the employee's money if the money
used to make the payment was:
cash which the employee had at death,
money which was in a bank account which was owned only by the employee;
money obtained by selling any of the employee's property;
unpaid wages which an employer was holding;
money from a trust fund or money from an insurance policy which the employee owned, if there was no beneficiary or if all
the beneficiaries died before the employee;
any payment made to a funeral home by the employee prior to the employee's death as part of a pre-need burial plan.
Other Person's Money
Any portion of the burial expenses which has been paid using funds other than those considered to be your own money or the
employee's money should be shown as expenses paid with any other person's money. The term "person" can be applied to an
individual, partnership, organization, fraternal association or government unit.
Reimbursement
The lump-sum death payment may be paid as a reimbursement to the person(s) who paid the employee's burial expenses. An
individual who receives the lump-sum death payment on this basis agrees not to request or accept reimbursement from
another party for that part of the burial expenses reimbursed by the lump-sum death payment.
You must submit proof of payment of the burial expenses. Part V of the booklet RB-21, Lump-Sum Death Payment, Residual
Lump-Sum, and Annuities Unpaid at Death, explains what proof is acceptable. If there are certain expenses such as flowers,
telegrams, phone calls or payments for religious ceremony for which you did not receive a receipt, use Section 8 to list the
expenses and the amount of each expense.
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‘7
Note: If you are applying on behalf of a medical school, dental school, or
anatomical board, use Section 8 to show the date of final disposition of
the employee's body (that is, the date when the body was buried or when
the ashes from the cremation are scattered or otherwise put to rest). If
there has been no final disposition of the body, indicate that in Section 8.
Page 15
)
Form AA-21 (11-08)
| File Type | application/pdf |
| File Modified | 2009-05-21 |
| File Created | 2009-05-21 |