AA-17sum (09-15) ( Application Summary

United States of America
Railroad Retirement Board

CURRENT (COMPLETED)

Form Approved
OMB 3220-0030

APPLICATION SUMMARY FOR A WIDOW(ER)’S ANNUITY

Employee’s Name
RR Claim No.

Elizabeth Michaels
A 929-48-7489

The following information was either supplied by or verified by you in support of your application for a
Widow(er)’s Annuity 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 which may be
punishable by fines, imprisonment or both.
Employee Information
Social Security Number
Date of Birth
Date of Death

929-48-7489
01/02/1940
08/02/2005

Military Service
The employee was not in active military service after September 7, 1939.
Recent Employment
The employee worked for the following companies in the last two years:
Star Stainless

from 05/20/1997 to 08/01/2011

The employee did not have self-employment earnings in any of the last three years.
Railroad Employment
The employee had a current connection with the railroad industry.
Employee’s Family
The employee was not survived by a child who may be entitled to monthly benefits.
RRB Form AA-17sum (09-15)

92948 74890 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0030

The employee was not survived by a grandchild who may be entitled to monthly benefits.
The employee was survived by a widow(er) or surviving divorced spouse who may be entitled to
monthly benefits.
Justin Michaels
Widow(er)
The employee was survived by a parent who may be entitled to monthly benefits.
Michael Michaels
Father
Applicant Information
Name and Address

Daytime Telephone Number
Social Security Number
Date of Birth

Justin Michaels
844 N Rush Street
Chicago IL 60611
312-555-1212
929-48-8479
06/06/1945

Type of Application Filed
Application Filing Date

Widow(er)’s Annuity
09/17/2012

You applied for this benefit based on your relationship to the employee.
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.
Applicant’s Marriages
You were not married to anyone other than the employee.
You have not remarried since the employee’s death.
Criminal Offense Information
Within the past 12 months you have not been imprisoned or been given a sentence of confinement
due to a conviction for a criminal offense.
Other Government Benefits
You are not receiving a Social Security benefit.

RRB Form AA-17sum (09-15)

92948 74890 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0030

In the past month you have filed or plan to file in the next three months for Railroad Retirement
benefits based on your own earnings.
You are not receiving a Railroad Retirement annuity.
You are not receiving nor do you expect to receive a pension or lump-sum payment based on your
earnings from a Federal, state or local government agency.
Earnings Information
In 2011, your total earnings were less than $14,640.00.
In 2012, you expect your total earnings will be $25,720.00.
Railroad Work
You have not worked for a railroad, railroad labor organization or other employer in the railroad
industry.
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.
Medicare
You are enrolled in the Medicare Medical Insurance Plan (Part B).
Your application for a Widow(er)’s Annuity has been released and will be processed as quickly as
possible. If you do not receive notification about your application by December 2, 2012 you should
contact the field office shown below.
You have received and reviewed the booklets RB-17, Survivor Annuities, RB-9s, Events that Affect a
Survivor Annuity, and Form G-77, How Earnings Affect Payment of Survivor Annuities. 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 criminal and/or civil prosecution.
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 you prefer.
RRB Form AA-17sum (09-15)

92948 74890 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0030

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

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Marriage – If you remarry.
Social Security – If you file for social security benefits based on any person’s earnings record.
Public Pension – If you begin to receive a pension or receive a lump-sum payment based on
your earnings at an agency of the Federal, state or local government.
Earnings – If your earnings change. On your application you told us you expect your total
earnings for 2012 to be $25,720.
Railroad Work – If you go to work for a railroad or railroad labor organization or work in any
capacity in the railroad industry.
Address – If your address changes, even if your payments are sent to a financial organization.
Bank Account – If your financial organization or the account number at your financial
organization changes.
Applicant is in Your Care – If any person for whom you are receiving an annuity dies or leaves
your care.
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.

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.
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.

RRB Form AA-17sum (09-15)

92948 74890 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0030

To report any changes or ask questions, you should contact:
U.S. Railroad Retirement Board
Hale Boggs Federal Bldg
Suite 1045
500 Poydras Street
New Orleans LA 70130-3399
877-772-5772
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-17sum (09-15)

92948 74890 22000 06051 32704

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