AA-19, Application for Child's Annuity

CURRENT

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

FORM APPROVED
O.M.B. No. 3220-0030

DO NOT WRITE IN THIS SPACE
OFFICIALLY FILED
MONTH
DAY

APPLICATION
FOR
CHILD’S ANNUITY

YEAR

OFFICE NUMBER

APPROVED

DATE CODED
MONTH

APPLICATION NUMBER

DAY

YEAR

CODED BY

General Instructions

Section 1

Before you complete this application, be sure to read booklet RB-17, Survivor Annuities, which explains information you will
need to answer many of the questions in this application. Also be sure to read the important notices at the end of the booklet.
If filing for a child’s disability also complete Form AA-19a. If filing for a student’s annuity also complete Form G-315.
Type or print legibly in ink. If you need more space than is provided to answer a question, use Section 10 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, 2015, as:
MONTH

DAY

0 6

0 6

YEAR

2 0

1 5

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 the child, you must answer each question as it applies to the child.

Identifying Information

Section 2

Check the information entered by the Railroad Retirement Board (RRB) for Items 1 through 6 for accuracy.
 If the information is correct, go to Section 3.
 If the information is not correct, cross out the incorrect information and enter the correct information above it.
 If the information is missing, fill it in.
Employee
Identification

Applicant
Identification

1

EMPLOYEE’S NAME

2

EMPLOYEE’S SOCIAL SECURITY NUMBER

3

EMPLOYEE’S RAILROAD RETIREMENT CLAIM NUMBER

4

APPLICANT’S NAME

5

a

STREET ADDRESS

b

CITY AND STATE

c

ZIP CODE

d

COUNTY

6

DAYTIME TELEPHONE NUMBER
Form AA-19 (07-15) Destroy Prior Editions

Information About The Employee

Section 3

If a railroad retirement survivor benefit was previously received by someone, go to Section 4; otherwise go to Item 7.
Birth Date

7 Enter the employee’s date of birth.

Residence

8 Enter the state (or country if other than United States) which
was the employee’s permanent home at the time of death.

MONTH

DAY

YEAR

If the employee was age 62 or older when he or she died, go to Item 10.
Disability

9 Enter an “X” in the appropriate box:
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.

Military
Service

Please read the section “Credit for Employee’s Military Service” in the RB-17 booklet to find out how active
military service is determined.
10 Enter an “X” in the appropriate box:
The employee was in active military service after
September 7, 1939.

 Yes
 No

 Yes
 No

Go to Note and Item 11
Go to Item 13

Note: If answered “Yes,” you will have to submit proof of the employee’s military service. If you cannot submit
proof, show the branch of the service and the beginning and ending dates for each period of service in Section 10.

11 Enter an “X” in the appropriate box:
The employee had voluntary military service during the
period June 15, 1948, through December 15, 1950.

 Yes
 No

Go to Item 12
Go to Item 13

12 Enter an “X” in the appropriate box:
The employee had nonrailroad earnings after leaving the military
service and before returning to the railroad.

 Yes
 No

Recent
13 Regardless of whether the employee was retired at death, show the name and address of each railroad or nonEmployment

railroad employer for whom the employee performed any part-time or full-time work during the last 3 years he
or she worked. Print the name and address of the most recent employer in a, the second in b, and so on.
Enter the date each job began and ended.
Name and Address of Employer
Began

a. Name

Month

Street Address

Year

Began
Month

Ended
Year

Began
Month

Month

Year

Ended
Year

Month

City, State & ZIP Code

Self14 Enter an “X” in the appropriate box:
Employment

The employee was self-employed during any of the
last three calendar years.

15 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.
16 Enter an “X” in the appropriate box(es) to show the year
or years in which the employee’s net earnings from
self-employment were more than $400.
Form AA-19 (07-15)

Year

City, State & ZIP Code

c. Name
Street Address

Month

City, State & ZIP Code

b. Name
Street Address

Ended

Page 2

 Yes
 No

Go to Item 15
Go to Item 17

 Yes
 No

Go to Item 16
Go to Item 17

 This year
 Last year
 Year before last

Year

Railroad
Employment

Answer Items 17 and 18 only if the employee was alive on October 1, 1981, and he or she had at least 25 years
of railroad service; otherwise go to Item 19.
Please read the section “Requirements The Employee Must Have Met” in the RB-17 booklet to find out what special
conditions may apply if the employee was alive on October 1, 1981, and had at least 25 years of railroad service.
Note: You may be requested to submit proof to verify the statements made in Items 17 and 18.
17 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 1, 1975, or
was on furlough, leave of absence status, or absent because
of injury on October 1, 1975, and was never called back to
work for that employer.

 Yes
 No

18 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.

Go to Item 18
Go to Item 19

 Yes
 No

Employee’s 19 Print the requested information for each of the employee’s marriages. Print the most recent in a, the second
Marriages
most recent in b, and so on.
Answer if Marriage Ended for Reason
Other than Employee’s Death
Name of Employee’s
Wife or Husband
(if wife, include
maiden name)

Widow(er)

City and State
Married
(country if other
than United States)

Date
Married

a

Month

Day

Year

b

Month

Day

Year

c

Month

Day

Year

How Marriage
Ended
(Check One)

 Employee’s Death
 Spouse’s Death
 Divorce
 Annulment
 Employee’s Death
 Spouse’s Death
 Divorce
 Annulment
 Employee’s Death
 Spouse’s Death
 Divorce
 Annulment

Date Marriage
Ended
Month

Day

Year

Month

Day

Year

Month

Day

Year

Please read the section “Definition Of A Widow(er)’s Annuity” in the RB-17 booklet to find out what categories of
widow(er) may be eligible for a railroad retirement annuity.
20 Enter an “X” in the appropriate box:
There is a widow(er), remarried widow(er), or surviving divorced
spouse who may be eligible for a widow(er)’s annuity.

Parents

City and State
Marriage Ended
(country if other than
United States)

 Yes
 No

21 Enter an “X” in the appropriate box:
The employee was survived by a parent.

 Yes
 No

Go to Item 22
Go to Section 4

22 Enter an “X” in the appropriate box:
The parent was dependent on the employee for
one-half of his or her support.

 Yes
 No

Go to Item 23
Go to Section 4

23 Print the requested information for each dependent parent of the employee.
Name of Parent
a

Date of Birth
Month

Day

Year

Address and Telephone Number
Address
Telephone Number (include area code)

(
b

Month

Day

Year

)

Address
Telephone Number (include area code)

(
Page 3

)
Form AA-19 (07-15)

Information About Children

Section 4

Please read the section “Definition Of A Child’s Annuity” in the RB-17 booklet to find out what categories of children may be
eligible for a railroad retirement annuity.
Children

24 Print the requested information for every child for whom you are filing this application who may be entitled to
a child’s annuity. Print the youngest child in a, the second youngest in b, and so on. If a child does not have a
social security number, enter “TO BE SUBMITTED.”
Note: If Stepchild or Grandchild is checked below, you must also complete Form G-139, Statement
Regarding Contributions and Support of Children.
Child’s Full Name and
Social Security Number
a

b

c

d

e

Relationship to
Employee
(Check One)

 Natural
 Adopted
 Stepchild

 Grandchild
 Other

 Natural
 Adopted
 Stepchild

 Grandchild
 Other

 Natural
 Adopted
 Stepchild

 Grandchild
 Other

 Natural
 Adopted
 Stepchild

 Grandchild
 Other

 Natural
 Adopted
 Stepchild

 Grandchild
 Other

Enter an “X” in the
appropriate box:
The Child is Living
with Me

Date of Birth

Month

Day

Year

 Yes
 No

Month

Day

Year

 Yes
 No

Month

Day

Year

 Yes
 No

Month

Day

Year

 Yes
 No

Month

Day

Year

 Yes
 No

If every child in Item 24 is living with you, go to Item 26.
Children
Not Living
With
Applicant

25 Print the requested information for every child in Item 24 who is not living with you. Print the youngest in a.
First Name
of Child

Person with Whom Child is Living

Child’s Address

Name

Relationship to
Child

a
b
Legal
Guardian

26 Enter an “X” in the appropriate box:
A court has appointed a legal guardian for a child in Item 24.

 Yes
 No

Go to Item 27
Go to Item 28

27 Print the requested information for every child in Item 24 who has a court-appointed legal guardian.
Print the youngest child in a, etc.
First Name of Child

Name and Address of Guardian

a

b
Form AA-19 (07-15)

Page 4

Married
Children

28 Enter an “X” in the appropriate box:
One or more of the children in Item 24 is or has been married.

 Yes
 No

Go to Item 29
Go to Item 30

29 Print the requested information for every child in Item 24 who has ever been married. Print the youngest child in a.
Child’s Married Name

GrandChildren,
Other
Children

Date Married

Date Marriage Ended
if applicable

a

Month

Day

Year

Month

Day

Year

b

Month

Day

Year

Month

Day

Year

If “Natural” or “Adopted” was checked for every child in Item 24, go to Item 32.
30 Enter an “X” in the appropriate box:
Every “Grandchild” or “Other Child” in Item 24
was living with the employee at the time the employee died.

 Yes
 No

Go to Item 32
Go to Item 31

31 Print the requested information for every “Grandchild” or “Other Child” in Item 24 who was not living with the
employee at the time the employee died. Print the youngest child in a, etc.
Person with Whom Child Lived at the Time the Employee Died
First Name of Child

Address

Name

Relationship to Child

a

b

Children
For Whom
You Are
Not Filing

32 Enter an “X” in the appropriate box:
There is a child for whom I am not filing this application
who may be entitled to a child’s annuity.

 Yes
 No

Go to Item 33
Go to Item 34

33 Print the requested information for every child for whom you are not filing an application who may be entitled
to a child’s annuity. Print the youngest child in a, the next youngest in b, and so on.
Reason for Not Filing

Child’s Full Name
a

b

c

Section 5

Information About The Applicant

Identification 34 Enter an “X” in the appropriate box:

I am a child filing for myself.
Relationship

 Yes
 No

Go to Item 39
Go to Item 35

 Yes
 No

Go to Item 38
Go to Item 37

35 Print your relationship to the youngest child in Item 24.
36 Enter an “X” in the appropriate box:
My relationship to every child in Item 24 is the same.
Page 5

Form AA-19 (07-15)

Relationship 37 Print the requested information for every child for whom your relationship differs.
Con’t

Your Relationship to Child

Child’s Name
a
b
c
Social
Security
Number
Criminal
Offense

38 Enter your social security number if you are the
parent of at least one child in Item 24.
39 Enter an “X” in the appropriate box:
Within the past 12 months, a child named in Item 24 has been imprisoned or
given a sentence of confinement due to a conviction for a criminal offense.

 Yes
 No

Go to Item 40
Go to Section 6

40 Enter the date of the conviction.

Month

Day

Year

41 Enter the date of the sentence of confinement.

Month

Day

Year

42 Enter the date that confinement began.

Month

Day

Year

 Yes
 No

43 Enter an “X” in the appropriate box:
Has the confinement ended?

Month

44 Enter the date confinement ended.

Section 6

Go to Item 44
Go to Section 6
Day

Year

Information About Applicant’s Other Government Benefits

When answering Items 45 through 52, consider only the children listed in Item 24.
Social
Security
Benefits—
Filed For

45 Enter an “X” in the appropriate box:
An application has been filed for benefits under the Social
Security Act for any child.

 Yes
 No

Go to Item 46
Go to Item 47

46 Print the requested information for every child for whom a social security application has been filed. Use as
many lines as needed beginning with a.
Child’s Name

Person Whose Record
was Filed On

Social Security Number Filed On

a
b
c
Social
Security
Benefits—
Future
Filing

47 Enter an “X” in the appropriate box:
An application will be filed in the future for benefits
under the Social Security Act for any child.

 Yes
 No

Go to Item 48
Go to Item 50

 Yes
 No

Go to Item 51
Go to Section 7

48 Print the name of the person on whose record the child
will file.
49 Enter that person’s social security number.

Railroad
Retirement
Benefits

50 Enter an “X” in the appropriate box:
An application has been filed or will be filed for monthly railroad retirement benefits for any child based on
someone other than the employee.

Form AA-19 (07-15)

Page 6

Railroad
Retirement
Benefits
Con’t

51 Print the name of the person on whose record the
application has been filed or will be filed.
52 Enter that person’s Railroad Retirement Board claim
number, including the letter prefix.

Section 7

If only six numbers,
enter here

Prefix

Information About Work And Earnings

Please read the section “How Earnings Affect An Annuity” in the RB-17 booklet to find out how work and earnings can affect
a child’s annuity. Also, please refer to Form G-77, How Earnings Affect Payment of Survivor Annuities, for the exempt
amounts to use when answering Items 53 through 58.
When answering Items 53 through 60, consider only the children listed in Item 24.
Answer Items 53 and 54 only if the employee died before January 1 of this year.
Earnings
Last Year
________
(Year)

53 Enter an “X” in the appropriate box:
The total earnings of any child for all employment last year were
more than the annual earnings exempt amount shown on Form G-77.

 Yes
 No

Go to Item 54
Go to Item 55

54 Print the requested information for every child whose total earnings for last year were more than the annual
earnings exempt amount shown on Form G-77. Use as many lines as needed beginning with a.
2 Total Earnings for Last Year
(Show Dollars Only)

a 1 Child’s Name

$
3 Enter an “X” in the appropriate box:
Did the child earn more than the monthly earnings exempt amount in
employment for hire or perform substantial services in self-employment in
every month last year?
4 Enter an “X” next to each month last year in
which the child did not earn more than the
monthly earnings exempt amount or perform
substantial services in self-employment.

 Yes
 No

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

2 Total Earnings for Last Year
(Show Dollars Only)

b 1 Child’s Name

$
3 Enter an “X” in the appropriate box:
Did the child earn more than the monthly earnings exempt amount in
employment for hire or perform substantial services in self-employment in
every month last year?
4 Enter an “X” next to each month last year in
which the child did not earn more than the
monthly earnings exempt amount or perform
substantial services in self-employment.

 Yes
 No

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

2 Total Earnings for Last Year
(Show Dollars Only)

c 1 Child’s Name

$
3 Enter an “X” in the appropriate box:
Did the child earn more than the monthly earnings exempt amount in
employment for hire or perform substantial services in self-employment in
every month last year?
4 Enter an “X” next to each month last year in
which the child did not earn more than the
monthly earnings exempt amount or perform
substantial services in self-employment.
Earnings
This Year
________
(Year)

55 Enter an “X” in the appropriate box:
The total earnings of any child for all employment this year
will be more than the annual earnings exempt amount.
Page 7

 Yes
 No

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

 Yes
 No

Go to Item 56
Go to Item 57
Form AA-19 (07-15)

Earnings
This Year
Con’t

56 Print the requested information for every child whose total earnings for this year are expected to be more
than the annual earnings exempt amount. Use as many lines as needed beginning with a.
a

1 Child’s Name

2 Total Earnings for This Year
(Show Dollars Only)
$

3 Enter an “X” in the appropriate box:
Did the child earn more than the monthly earnings exempt amount in
employment for hire or perform substantial services in self-employment in
every month this year?
4 Enter an “X” next to each month this year in
which the child did not, or does not expect to,
earn more than the monthly earnings exempt
amount or perform substantial services in
self-employment.

 Yes
 No

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

2 Total Earnings for This Year
(Show Dollars Only)

b 1 Child’s Name

$
3 Enter an “X” in the appropriate box:
Did the child earn more than the monthly earnings exempt amount in
employment for hire or perform substantial services in self-employment in
every month this year?
4 Enter an “X” next to each month this year in
which the child did not, or does not expect to,
earn more than the monthly earnings exempt
amount or perform substantial services in
self-employment.
c

 Yes
 No

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

2 Total Earnings for This Year
(Show Dollars Only)

1 Child’s Name

$
3 Enter an “X” in the appropriate box:
Did the child earn more than the monthly earnings exempt amount in
employment for hire or perform substantial services in self-employment in
every month this year?
4 Enter an “X” next to each month this year in
which the child did not, or does not expect to,
earn more than the monthly earnings exempt
amount or perform substantial services in
self-employment.
Earnings
Next Year
________
(Year)

 Yes
 No

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

57 Enter an “X” in the appropriate box:
The total earnings of any child for all employment next year will be
more than this year’s annual earnings exempt amount.

 Yes
 No

Go to Item 58
Go to Item 59

58 Enter the requested information for every child whose total earnings for next year are expected to be more
than the annual earnings exempt amount. Use as many blanks as needed beginning with a.
Expected Earnings Next Year
(Show Dollars Only)

Child’s Name
a

$

b

$

c

$

Form AA-19 (07-15)

Page 8

Railroad
Work

 Yes
 No

59 Enter an “X” in the appropriate box:
Any child who has worked for a railroad or other employer
in the railroad industry.

Go to Item 60
Go to Section 8

60 Print the requested information for every child who has worked for a railroad or other employer in the railroad
industry. Use as many lines as are needed beginning with a.
a

1 Child’s Name

2 Railroad Employer

3 Date Last Worked

Month

4 Enter an “X” next to each month in this year
during which the child worked for an employer
in the railroad industry.

5 If you expect the annuity to begin before January
1st of this year, enter an “X” next to each month of
the last year during which the child worked for an
employer in the railroad industry.
b

Year

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

1 Child’s Name

2 Railroad Employer

3 Date Last Worked

Month

4 Enter an “X” next to each month in this year
during which the child worked for an employer
in the railroad industry.

5 If you expect the annuity to begin before January
1st of this year, enter an “X” next to each month of
the last year during which the child worked for an
employer in the railroad industry.
c

Day

Day

Year

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

1 Child’s Name

2 Railroad Employer

3 Date Last Worked

Month

4 Enter an “X” next to each month in this year
during which the child worked for an employer
in the railroad industry.

5 If you expect the annuity to begin before January
1st of this year, enter an “X” next to each month of
the last year during which the child worked for an
employer in the railroad industry.

Section 8

Day

Year

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Filing Date

Answer only if you are disabled or otherwise eligible for social security disability or survivor benefits and you have not filed
an application for such benefits.
Filing
Protection

61 Enter an “X” in the appropriate box:
I also want this application used to protect my filing date
for social security benefits.
Page 9

 Yes
 No
Form AA-19 (07-15)

Section 9

Receiving Your Payments

All applicants filing for RRB benefits must choose to receive their annuity payments either:



By Direct Deposit to a bank, savings and loan, credit union or other financial institution; or
Into a Direct Express® Debit MasterCard® account.

Please read Part VII of the RB-17 booklet for an explanation of Direct Deposit and the Direct Express® Debit MasterCard®.
Payment
Options

Direct
Deposit

62 Enter an “X” in the appropriate box to indicate how you
want to receive your payments.



Direct Deposit - Go to Item 63



Direct Express® Debit MasterCard®
Go to Section 10



Neither Direct Deposit nor Direct Express®
Debit MasterCard® - Go to Section 10

To provide the information we need to correctly deposit your payments by Direct Deposit, either attach a voided
personal check and go to Section 10, or call your financial institution for the information you need to complete
Items 63 through 67 below.

63 Enter the name of your financial institution.
Area Code

64 Enter the telephone number of your
financial institution.

Telephone Number

65 Enter the routing transit number of your
financial institution.
66 Enter your account number.
67 Enter an “X” in the appropriate box:
Type of account for the above account number.

 Checking
 Savings
Go To Section 10

Section 10
Remarks

Remarks

68 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-19 (07-15)

Page 10

Certification

Section 11

Certification 69 Enter an “X” in the appropriate box:

 Yes
 No

I will have a guardian or other representative sign
this application on my behalf.

Go to Note and Item 70
Go to Item 70

Note: If answered “Yes,” your guardian or other representative must sign this application. That person
must also complete and return Form AA-5, Application for Substitution of Payee.
70 I certify that the information I gave the Railroad Retirement Board (RRB) on this application is true to the best
of my knowledge. I know that if I make a false or fraudulent statement or withhold information in order to
receive benefits from the RRB, I am committing a crime under Federal law which may be punishable by fines,
imprisonment, or both. I have received and reviewed the booklets, RB-17, Survivor Annuities and RB-9s,
Events That Affect A Survivor Annuity. I understand that I am responsible for reporting events that would
affect my annuity as explained in the booklets.
I agree to immediately notify the RRB:
•
•
•
•
•
•
•
•
•
•

If I / any child marries;
If I / any child over age 18 ceases to attend school full time;
If an application is filed for social security benefits on any person’s earnings record;
If I / any child goes to work for a railroad, railroad labor organization or work in any capacity in the railroad industry;
If I / any child will earn more than the annual earnings exempt amount, and it was not reported on the
application;
If the reported earnings estimate changes;
If my address changes;
If my financial organization or the account number at my financial organization changes;
If any child for whom I am receiving benefits dies or leaves my care;
If I am, or any child is, confined in a jail, prison, penal institution, or correctional institution due to a
conviction for a criminal offense.



Signature
(First Name, Middle Initial,
Last Name)

Month

Year



Date

Day

71 If this certification is signed by mark (“X”) in Item 70, 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, and ZIP Code

Area Code

Telephone Number

Area Code

Telephone Number

Daytime Telephone Number
b. Signature of Witness

Address (Number and Street)

City, State, and ZIP Code

Daytime Telephone Number
Page 11

Form AA-19 (07-15)

Section 12

How To Return Your Application

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 the child’s 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 office serving your
location. 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 Service will not deliver your application unless it has the correct postage.
Make one final check before you seal the envelope to ensure that the following are enclosed:
 NEEDED PROOFS
 THE APPLICATION FORM ITSELF
 ADDITIONAL FORMS YOU WERE ASKED TO COMPLETE

Note: After the RRB receives the child’s application, a receipt form with information about the claim
will be sent to you. When you receive it, you will know that the RRB has received the application
and has started the work needed to determine if the child is entitled to benefits. If you do not
receive the receipt within two weeks after you have filed this application, please contact us so we
can find out what is causing the delay.

Form AA-19 (07-15)

Page 12