AA-17, Proposed (less than 10 responses)

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

PROPOSED
DO NOT WRITE IN THIS SPACE
OFFICIALLY FILED
MONTH
DAY

Application
for
Widow(er)’s Annuity

YEAR

OFFICE NUMBER

APPROVED

APPLICATION NUMBER

DATE CODED
MONTH

DAY

YEAR

CODED BY

Section 1

General Instructions

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 widow(er)’s disability also complete Form AA-17b.
Type or print legibly in ink. If you need more space than is provided to answer a question, use Section 9 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

YEAR

0 6 0 6 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 someone else, you must answer each question as it applies to the applicant.

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

OMB Approval Not Required (<10 Responses Annually)

Form AA-17 (xx-xx) Destroy Prior Editions

Section 3

Information About The Employee

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

7

Day

Month

Enter the employee’s date of birth.

Year

If the employee was age 62 or older when he or she died, go to Item 9.
Disability

8

Military
Service

Please read the section “Credit for Employee’s Military Service” in Part V of the RB-17 booklet to find out
how active military service is determined.
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.

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 10
Go to Item 12

Note: If answered “Yes,” you will have to submit proof of the employee’s military
service. If you cannot submit proof show, in Item 83, the branch of the service
and the beginning and ending dates for each period of service.
10 Enter an “X” in the appropriate box:
The employee had voluntary military service during the
period June 15, 1948, through December 15, 1950.
11 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

Go to Item 11
Go to Item 12

 Yes
 No

Recent
12 Regardless of whether the employee was retired at death, show the name and address of each railroad or
Employment
nonrailroad 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 12a, the second in 12b,
and so on. Enter the date each job began and ended.
Name and Address of Employer
a Name

Began

Address

Month

Year

Ended
Month

Year

City, State, ZIP Code

b Name

Began

Address

Month

Year

Ended
Month

Year

City, State, ZIP Code

c Name

Began

Ended

Address
Month

Year

Month

City, State, ZIP Code
Self13 Enter an “X” in the appropriate box:
Employment
The employee was self-employed

 Yes
 No

Go to Item 14
Go to Item 16

14 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.

 Yes
 No

Go to Item 15
Go to Item 16

15 Enter an “X” in the appropriate box(es):
Show the year or years in which the employee’s net
earnings from self-employment were more than $400.

 This year
 Last year
 Year before last

during any of the last three calendar years.

Form AA-17 (xx-xx)

Page 2

Year

Railroad
Employment

Answer Items 16 and 17 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 18.
If the employee was alive on October 1, 1981, and had at least 25 years of railroad service, read the section
“Requirements the Employee Must Have Met” in Part I of the RB-17 booklet to find out what special conditions
may apply.
Note: You may be requested to submit proof to verify the statements
made in Items 16 and 17.
16 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

17 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 17
Go to Item 18

 Yes
 No

Employee’s 18 Enter the requested information for each of the employee’s marriages. Print the most recent marriage in 18a,
Marriages
the second most recent in 18b, 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)

a

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

Date
Married
Month Day

How Marriage
Ended
(check one)

Date Marriage
Ended

 Employee’s Death
Month Day
 Spouse’s Death

Year

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

Year

 Divorce
 Annulment

b

Month Day

 Employee’s Death
Month Day
 Spouse’s Death

Year

Year

 Divorce
 Annulment

c

Month Day

 Employee’s Death Month Day
 Spouse’s Death

Year

Year

 Divorce
 Annulment
Children

Please read the section “Definition Of A Child’s Annuity” in Part II of the RB-17 booklet to find out what categories
of children may be eligible for a railroad retirement annuity.
19 Enter an “X” in the appropriate box:
There are children who may be eligible
for a annuity.

 Yes
 No

Go to Item 20
Go to Item 21

20 Enter the number of children who may be eligible for an annuity.
Page 3

Form AA-17 (xx-xx)

Parents

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 Enter the requested information for each dependent parent of the employee.
Name of Parent

Date of Birth

a

Day

Month

Year

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

b

Day

Month

Year

Address
Telephone Number (include area code)
(
)

Section 4
Birth Date
Social
Security
Number
Marriages

Information About The Applicant
Month

24 Enter your date of birth.

Day

Year

25 Enter your social security number.
(If none, enter “To be submitted.”)
26 Enter an “X” in the appropriate box:
I am now, or was previously, married to
someone other than the employee.

 Yes
 No

Go to Item 27
Go to Item 29

27 Enter the requested information for each of your marriages to someone other than the employee.
Print the most recent marriage in 27a, the second most recent in 27b, and so on.

Your Husband’s or
Wife’s Name and
Social Security Number
(do not show employee)

a

Name

b

Name

c

Name

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

Date
Married
Month Day

Year

Month Day

Year

Month Day

Year

If Marriage Never Ended, Leave These Blank
How Marriage
Ended
(check one)










Date Marriage
Ended

Spouse’s Death Month Day
Divorce
Annulment
Spouse’s Death Month Day
Divorce
Annulment
Spouse’s Death Month Day
Divorce
Annulment

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

Year

Year

Year

28 Answer only if any of the social security numbers requested in Item 27 are unknown. If more than one social
security number is unknown, enter the information requested in this item in Section 9 for each additional
unknown number.
a Enter the name of the husband or wife
whose social security number is unknown.
b Enter that husband’s or wife’s date of birth.
c Enter that husband’s or wife’s place of birth.
Item 28 continues on the next page.
Form AA-17 (xx-xx)

Page 4

Month

Day

Year

Marriages
(cont.)

28 d Enter that husband’s or wife’s father’s name.
e Enter that husband’s or wife’s mother’s maiden name.

Support

If you and the employee were divorced, go to Item 35.
29 Enter an “X” in the appropriate box:
The employee and I were living together when the employee died.
If “Yes,” and you are male, go to Item 34. If “Yes,” and you are female,
go to Item 35.
30 Enter the date you and the employee stopped living together.

 Yes
 No
Month

Go to Item 30
Day

Year

31 Enter the reason you and the employee
stopped living together.
32 Enter an “X” in the appropriate box:
The employee was making regular contributions to my support when the
employee died. If “Yes,” and you are male, go to Item 34.
If “Yes,” and you are female, go to Item 35.
(Note: Consider the following as contributions to support:
money, food, clothes, paying bills, providing rent-free housing.)
33 Enter an “X” in the appropriate box:
The employee was under a court order to contribute to my
support.
(Note: Answer “Yes” if there was a court order, even if
the employee was not obeying it.)
One-Half
Support

 Yes
 No

Go to Item 33

 Yes

Go to Item 35

 No

Go to Item 35

Answer Item 34 only if you are working or have ever worked in the railroad industry, and Items 29 or 32 was answered “Yes.”
34 Enter an “X” in the appropriate box:
The employee’s contributions to me provided at least
one-half of the money needed to support me.

 Yes

Go to Note and Item 35

 No

Go to Item 35

 Yes

Go to Item 36

 No

Go to Section 5

Note: If answered “Yes,” complete and return to the RRB,
Form G-134, Statement Regarding Contributions and Support.
Criminal
Offense

35 Enter an “X” in the appropriate box:
Within the past 12 months, I have been imprisoned or given a
sentence of confinement due to a conviction for a criminal offense.
36 Enter the date of the conviction.
37 Enter the date of the sentence of confinement.
38 Enter the date that confinement began.

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

Month

Day

Year

Month

Day

Year

Month

Day

Year

 Yes

Go to Item 40

 No

Go to Section 5

Month

40 Enter the date confinement ended.
Page 5

Day

Year

Form AA-17 (xx-xx)

Section 5
Public
Service
Pension

Information About Applicant’s Other Government Benefits

41 Enter an “X” in the appropriate box:
I am receiving or expect to receive a pension or I have
received or expect to receive a lump-sum payment instead
of a pension, based on my earnings, from an agency of the
Federal, state, or local government.

 Yes
 No

Go to Item 42
Go to Item 44

 Yes
 No

Go to Note and Item 44
Go to Item 43

(Answer “No” if your only government pension payments
are social security, railroad retirement, veterans affairs,
worker’s compensation, or black-lung benefits. Also,
answer “No” if you received a lump-sum payment that was
just your contributions to the pension fund plus interest.)
42 Enter an “X” in the appropriate box:
I am/was an employee of the Federal Government.

Note: If answered “Yes,” complete and return to the RRB, Form G-208,
Public Service Pension Questionnaire, and verification of your pension.
43 Enter an “X” in the appropriate box:
In my last 60 months of employment, I was employed by a state or
local government or the military service, and social security (FICA)
taxes were being deducted from my public service earnings.

 Yes
 No

Go to Item 44
Go to Note and Item 44

Note: If answered “No,” complete and return to the RRB, Form G-208,
Public Service Pension Questionnaire, and verification of your pension.

Social
Security
Benefits

44 Enter an “X” in the appropriate box:
I have filed, or plan to file, an application for benefits
under the Social Security Act.

 Yes
 No

Go to Item 45
Go to Item 48

45 Enter an “X” in the appropriate box:
I have filed, or plan to file, for social security benefits
based on the record of someone other than myself.

 Yes
 No

Go to Item 46
Go to Item 48

48 Enter an “X” in the appropriate box:
I have filed, or plan to file within 90 days, an application for
monthly railroad retirement benefits based on the record of
someone other than the employee.

 Yes
 No

Go to Item 49
Go to Section 6

49 Enter an “X” in the appropriate box:
I have filed, or plan to file, an application for railroad retirement
benefits based on my own railroad employment.

 Yes
 No

Go to Section 6
Go to Item 50

46 Enter the name of the person on
whose account you are filing.
47 Enter that person’s social security number.
Railroad
Retirement
Benefits

50 Enter the name of the person on whose
record you have filed or will file.
51 Enter that person’s Railroad Retirement Board claim
number, including the letter prefix.
Form AA-17 (xx-xx)

Page 6

Prefix

If only six numbers,
enter here

Section 6

Information About Work And Earnings

Please read the section “How Earnings Affect An Annuity” in Part V of the RB-17 booklet to find out how work and earnings
can affect your railroad retirement annuity. Also, please refer to Form G-77, How Earnings Affect Payment of Survivor
Annuities, for the exempt amounts to use when answering Items 52 through 61.
Earnings
Last Year
________
(Year)

If you were full retirement age or older when the employee died, or you are now full retirement age or older,
go to Item 62.
Answer Items 52 through 55 only if you were age 60 or older last year and the employee died before January 1 of this year.
52 Enter an “X” in the appropriate box:
My total earnings for all employment last
year were more than the annual earnings
exempt amount shown on Form G-77.

 Yes
 No

53 Enter your total earnings for last year.
(SHOW DOLLARS ONLY)

$

54 Enter an “X” in the appropriate box:
I earned more than the monthly earnings
exempt amount in employment for hire or
performed substantial services in
self-employment in every month last year.

 Yes
 No

55 Enter an “X” next to each month last year in
which you did not earn more than the monthly
earnings exempt amount or perform substantial
services in self-employment.

Earnings
This Year

Go to Item 53
Go to Item 56

Go to Item 56
Go to Item 55

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Answer Items 56 through 59 only if you are age 60 or older, or will become age 60 this year.

______
(Year)

56 Enter an “X” in the appropriate box:
I expect my total earnings for all employment
this year to be more than the annual earnings
exempt amount.

57 Enter the total amount that you expect to earn this year.
(SHOW DOLLARS ONLY)

58 Enter an “X” in the appropriate box:
I expect to earn more than the monthly earnings
exempt amount in employment for hire or to perform
substantial services in self-employment in every
month this year.

Page 7

 Yes
 No

Go to Item 57
Go to Item 60

$

 Yes
 No

Go to Item 60
Go to Item 59

Form AA-17 (xx-xx)

Earnings
This Year
(Cont.)

Earnings
Next Year
_______
(Year)

59 Enter an “X” next to each month this year in which
you did not, or do not expect to, earn more than
the monthly earnings exempt amount or perform
substantial services in self-employment.

60 Enter an “X” in the appropriate box:
I expect my total earnings for all employment
next year to be more than this year’s annual
earnings exempt amount.

61 Enter the total amount that you expect to earn next year.

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

 Yes
 No

Go to Item 61
Go to Item 62

$

(SHOW DOLLARS ONLY)
Railroad
Work

62 Enter an “X” in the appropriate box:
I have worked for a railroad or other
employer in the railroad industry.

 Yes
 No

Go to Item 63
Go to Section 7

63 Enter the name of your last railroad employer.

64 Enter the date you last worked for this employer.

65 Enter an “X” next to each month in this
year during which you worked, or you
expect to work, for an employer in the
railroad industry.

Month

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

Complete Item 66 only if you expect your annuity to begin before January 1 of this year.

66 Enter an “X” next to each month of last year during
which you worked for an employer in the railroad
industry.

Form AA-17 (xx-xx)

Page 8

Section 7
Selecting a
Beginning
Date

Beginning Dates, Filing Dates, And Medicare

If you are under full retirement age on the date your annuity begins, your annuity will be reduced for early retirement.

67 Enter an “X” in the appropriate box:
I want my annuity to begin on the earliest
date permitted by law, even if I will receive
a reduced annuity.

 Yes
 No

68 Since you do not want your annuity to begin on the
earliest date permitted by law, enter the date you want
your annuity to begin.

Month

Go to Item 69
Go to Item 68

Day

Year

Note: If the date you select is more than 3 months after you return
this application, you will need to file an updated application.
Filing
Protection

Answer only if you are age 62 or older, disabled, or otherwise eligible for social security old age, disability,
or survivor benefits and you have not filed an application for such benefits.
69 Enter an “X” in the appropriate box:
I also want this application used to protect my
filing date for social security benefits.

Medicare

 Yes
 No

Please read the section “Medicare Benefits” in Part VIII of the RB-17 booklet for an explanation of the Medicare
program.
70 Enter an “X” in the appropriate box:
I am enrolled in the Medicare Medical
Insurance (Part B).

 Yes
 No

Go to Item 71
Go to Item 73

71 Enter the name of the agency where you have filed for Medicare.

72 Enter your Medicare claim number.
Go to Section 8
73 Enter an “X” in the appropriate box:
I am 64 years and 5 months of age or older.

 Yes
 No

Go to Item 74
Go to Section 8

74 Enter an “X” in the appropriate box:
I wish to enroll in the Medicare Medical
Insurance (Part B).

 Yes
 No

Go to Item 75
Go to Section 8

75 Enter an “X” in the appropriate box:
I am claiming a special enrollment period
based on coverage by an employer group
health plan.

 Yes
 No

76 Enter an “X” in the appropriate box:
I am claiming premium surcharge relief based on
coverage by an employer group health plan.

 Yes
 No

Page 9

Form AA-17 (xx-xx)

Section 8

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

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



Direct Deposit - Go to Item 78



Direct Express® Debit MasterCard®
Go to Section 9



Neither Direct Deposit nor Direct Express®
Debit MasterCard® - Go to Section 9

To provide the information we need to correctly deposit your payments by Direct Deposit, either attach a voided
personal check and go to Section 9, or call your financial institution for the information you need to complete
Items 78 through 82 below.

78 Enter the name of your financial institution.
Area Code

Telephone Number

79 Enter the telephone number of your financial institution.

80 Enter the routing transit number of your financial institution.
81 Enter your account number.
82 Enter an “X” in the appropriate box:
Type of account for the above account number.

 Checking
 Savings
Go to Section 9

Section 9
Remarks

Remarks

83 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-17 (xx-xx)

Page 10

Section 10
Certification

84

Certification
Enter an “X” in the appropriate box:
I will have a guardian or other representative sign
this application on my behalf.

 Yes
 No

Go to Note and Item 85
Go to Item 85

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.
85 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 remarry;
If I begin to receive a pension from an agency of the Federal, state, or local government, or if my present
payments change;
If I file for social security benefits based on any person’s earnings record;
If I go to work for a railroad, railroad labor organization or work in any capacity in the railroad industry;
If I will earn more than the annual earnings exempt amount, and it was not reported on the application;
If I reported expected earnings and my earnings estimate changes;
If my address changes;
If my financial organization or the account number at my financial organization changes;
If any person for whom I am receiving benefits dies or leaves my care;
If I am 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

Day

Year

Date
86 If this certification is signed by mark (“X”) in Item 85, 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
Area Code

Telephone Number

Area Code

Telephone Number

Daytime Telephone Number
b Signature of Witness
Address (Number and Street)
City, State, ZIP Code

Daytime Telephone Number
Page 11

Form AA-17 (xx-xx)

Section 11

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 hich 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 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 your application, a receipt form with information about your claim will
be sent to you. When you receive it, 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 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-17 (xx-xx)

Page 12