AA-21, All Possible

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0031

APPLICATION SUMMARY and CER'TIFICATION
Employee's Name
RR Claim No.

The following information was either supplied by or verified by you in support of your
application for Lump Sum Death Payment
Annuity Unpaid at Death
Railroad Tax Refund
SMlB Refund
Residual Lump Sum Death Payment 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.
Employee Information
Social Security Number
Date of Birth
Date of Death
Military Service
1. The employee was not in active military service after September 7, 1939.
2. The employee had military service after September 7, 1939.
Recent Err~ployme~it

3. The employee has not worked in the last three years.
4. The employee worked for the following companies in the last two years:
from 99/99/9999 to 99/99/9999
(Company Name)
(Company Name)
from 99/99/9999 to 99/99/9999
(Company Name)
from 99/99/9999 to 99/99/9999
5. The employee did not have self-employment earnings in any of ,the last three years.
6. The employee's net earnings from self-employment were less than $400 in each of
the last three years.
RRB Form AA-21 cert (02-00)

32948 64791 21999 06051 32704

Page I

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0031

7. The employee's net earnings from self-employment were $400 or more in one of the
last three years.
Railroad Employment
8. The employee had a current connection with the railroad industry.

9. A current cor~nectionwith the railroad industry is "deemed" because the employee:
1
2

3

Was alive on October 1, 1981 and had at least 25 years of railroad service, and
Alnvoluntarily and without fault" stopped working for the railroad on or after
October 1, 1975 and was never called back to work forthe railroad employer,
and
Did 110t decline an offer froni a railroad employer to return to a job in the same
Aclass or craft" as the last railroad job.

10.The employee does not have a current connection with the railroad industry.
Employee's Family
(Application LSDP or RLS to Widow(er))
11.You are not eligible for monthly benefits.

12.You are eligible for monthly benefits.
13.The employee was not survived by a surviving divorced spouse who is eligible for
monthly benefits.
14.The employee was survived by a surviving divorced spouse who is eligible for monthly
benefits.
15.The employee was survived by a surviving divorced spouse who is not eligible for
monthly benefits.
16.The employee was not survived by children or grandchildren who are eligible for
monthly benefits.
17.The employee was survived by children or grandchildren who are eligible for monthly
benefits.
18.The employee was 110t survived by a parent who is eligible for monthly benefits.
19.The employee was survived by a parent who is eligible for monthly benefits.
RRB Form AA-2lcert (02-00)

32948 64791 21999 06051 32704

Page 2

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0031

(LSDP PBIE or RLS des bene)
20.The employee was not survived by a widow(er) who is eligible for monthly benefits.
21 .The employee was survived by a widow(er) who is not eligible for monthly benefits.
22.The employee was survived by a widow(er) who is eligible for monthly benefits.
23.The employee was not survived by a surviving divorced spouse who is eligible for
monthly benefits.
24.The employee was survived by a surviving divorced spouse who is eligible for monthly
benefits.
25.The employee was survived by a surviving divorced spouse who is not eligible for
monthly benefits.
26.The employee was not survived by children or grandchildren who are eligible for
monthly benefits.
27.The employee was survived by children or grandchildren who are eligible for monthly
benefits.
28.The employee was not survived by a parent who is eligible for monthly benefits.
29.The employee was survived by a parent who is eligible for montl-~lybenefits.
(AA to P BIE)
30.The employee was not survived by a widow(er).
(AA, TR, SALSA, RLS to Rel)
31 .The employee was not survived by a widow(er).
32.The employee was survived by a widow(er)
(REL Child)
33.The employee was survived by other children.
34.The employee was not survived by other children.
(REL Gchild)
35.The employee was not survived by children.
RRB Form ,414-2lcert (02-00)

32948 64791 21999 06051 32704

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Form Approved
OMB 3220-0031

United States of America
Railroad Retirement Board

36.The employee was survived by children.
37.The employee was not survived by other grandchildren.
38.The employee was survived by other grandchildren.
(REL Parent)
39.The employee was not survived by children.
40.The employee was survived by children.
41 .The employee was not survived by grandchildren.
42.The employee was survived by grandchildren.
(REL 6 & S)
43.The employee was not SI-wived by children
44.The employee was survived by children.
45.The employee was not survived by grandchildren.
46.The employee was survived by grandchildren.
47.The employee was not survived by parents.
48.The employee was survived by parents.
49.The employee was not survived by other brothers and sisters.
5O.The employee was survived by other brothers and sisters.
Applicant Information
Name and Address
Social Security Number
Daytime Telephone Number
Type of Application Filed
RRB Form AA-21 cert (02-00)

Lump Sum Death Payment
Annuity Unpaid at Death
32948 64791 21999 06051 32704

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Form Approved
OMB 3220-0031

United States of America
Railroad Retirement Board

Railroad Tax Refund
Residual Lump Sum Death Payment
51.You applied for this benefit based on being the employee's "living-with" spouse at the
time of death.
52.You applied for this benefit based on being responsible for the payment of the
ernployee's burial expenses.
53.You applied for this benefit based on being the f~meralhome responsible for the final
disposition of the employee's remains.
54.You applied for this benefit based on your relationship to the employee.
55.You have requested that any payment due you be sent to the following bank account:
Bank Name
Routing Number
Account Number
Account Type
56.You have requested that any payment due you be sent to the address shown above.
57.You have requested that any payment due you be sent to the following bank account:
Bank Name
Routing Number
Account Number
Account Type
58.You have requested that any payment due you be sent to the address shown above.
59.You have requested that any payment due the employee's estate be sent to the following
bank account:
Bank Nanie
Routing Number
Account Number
Account Type
6O.You have requested that any payment due the employee's estate be sent to the following
RRB Form AA-2lcert (02-00)

32948 64791 21999 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0031

address.
Burial Expense Information
61 .Total funeral home expenses:

$99,999.99

62.Amount paid with your own money:

$99,999.99

63.Amount paid with the employee's money:

$99,999.99

64.Amount paid with someone else's money:

$99,999.99

65.Amount remaining unpaid:

$99,999.99

66.Total cost of the grave opening and closing:

$99,999.99

67.Amo1.1ntpaid with your own money:

$99,999.99

68.Amount paid with the employee's money:

$99,999.99

69.Amount paid with someone else's money:

$99,999.99

70.Total cost of the burial plot:

$99,999.99

71 .Amount paid with your own money:

$99,999.99

72.Amount paid with the employee's money:

$99,999.99

73.Amount paid with someone else's money:

$99,999.99

74.Total cost of other burial expenses:

$99,999.99

75.Amount paid with your own money:

$99,999.99

76.Amount paid with the employee's money:

$99,999.99

77.Amount paid with someone else's money:

$99,999.99

Assutr~ptio~i
of Responsibility
78.You have assumed responsibility for the payment of the unpaid funeral home
expenses.
RRB Form AA-2lcert (02-00)

32948 64791 21999 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0031

Authorization of Payment
79.You have authorized payment of the lump-sum deatli payment to
Reimbursement
80.You have not and will not receive money or property to reimburse you for the burial
expenses you paid.
81.You have received or expect to receive $99,999.99 [Insert total amount of 2638-BEREIMB-AMT] to pay you back for the burial expenses you paid.
Estate
82.The court appointed administrator or executor of the employee's estate is:
xxXXXXXXXxXXXXXXxxXX
XXXxxxxxxxxxxXXxxxxX
xxxxxxxxxXXXXXXxxXXX
83.The trustee of the employee's estate is:
xxxxxxxxxxxXXXXXxxXX
xxxxxXXXXxxxXXXXxxXX
84.The representative of the employee's estate is:
XXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXX

85.A representative for the err~ployee'sestate has not been appointed.
Application for Lump Sum Death Payment
Annuity Unpaid at Death
Railroad Tax Refund
SMlB Refund
Residual Lump Sum Death Payment
- Certification
Employee's RR Claim Number
RRB Form AA-21cert (02-00)

32948 64791 21999 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0031

Employee's Name
Employee's Social Security Number
Applicant's Name
Applicant's Social Security Number
86.1 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 in order to receive benefits from the RRB, I am committing a
crime which is pur~ishableunder Federal law.
87.1 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 have made and initialed any corrections on the Summary being returned
to the RRB.
88. if the application type 2600-APPL-TYPE-CD = 11.

I 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.
89. if the application type is 2600-APPL-TYPE-CD=12.

I will either return the payment or refund the excess to the Railroad Retirement Board (RRB)
if payment is made to me by the RRB and the amount is greater than the unpaid expenses
at the time I receive the payment.
90.1 have received and reviewed the booklet RB-21 LUMP-SUM DEATH PAYMENT,
RESIDUAL LUMP-SUM, AND ANNUITIES UNPAID AT DEATH]

Sig naflire (First Name, Middle Initial, Last Name)

Date (MonthlDayNear)

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 number.

Signature of Witness

Signature of Witness

Address (Street, City, State and ZIP Code)

Address (Street, City, State and ZIP Code)

u
Daytime Telephone Number

(1
Daytime Telephone Number

RRB Form AA-2lcert (02-00)

32948 64791 21999 06051 32704

Page 8