AA-20 proposed (less than 10 responses)

PROPOSED

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

DO NOT WRITE IN THIS SPACE
OFFICIALLY FILED
DAY
MONTH

Application
for
Parent’s Annuity

YEAR

OFFICE NUMBER

APPROVED

APPLICATION NUMBER

DATE CODED
MONTH

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.
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

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.

Section 2

Identifying Information

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-20 (xx-xx) 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

Military
Service

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.

 Yes
 No

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

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, in Section 10, the branch of the service and the beginning and ending dates for each period of service.
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

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

Go to Item 12
Go to Item 13

 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 13a, the second in 13b, and so on.
Enter the date each job began and ended.
Name and Address of Employer
a

Name

Began

Ended

Address

Month

Year

Month

Year

City, State, ZIP Code

b

Name

Ended

Began

Address

Month

Year

Month

Year

City, State, ZIP Code

c

Name

Began

Ended

Address

Month

Year

Month

Year

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.
Form AA-20 (xx-xx)

Page 2

 Yes
 No

Go to Item 15

 Yes
 No

Go to Item 16

Go to Item 17

Go to Item 17

 This year
 Last year

Self16 Enter an “X” in the appropriate box(es):
Employment
Show the year or years in which the employee’s net
(Continued)

earnings from self-employment were more than $400.

 Year before last
Railroad
Answer Items 17 and 18 only if the employee was alive on October 1, 1981, and he or she had at least 25 years
Employment of railroad service; otherwise go to Item 19.

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 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.

Section 4
Widow(er)

Go to Section 4

 Yes
 No

Information About The Employee’s Family

Please read the section “Definition of a Widow(er)’s Annuity” in Part II of the RB-17 booklet to find out what
categories of widow(er) may be eligible for a railroad retirement annuity.
19 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.

Children

Go to Item 18

 Yes
 No

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.
20 Enter an “X” in the appropriate box:
There are children who may be eligible for an annuity.

 Yes
 No

Answer Item 21 only if the employee was male.
21 Enter an “X” in the appropriate box:
A child of the employee is expected to be born.

Section 5
Birth Date

 Yes
 No

Information About The Applicant

22 Enter your date of birth.

Month

Relationship 23 Enter an “X” in the appropriate box:

I am the employee’s only living natural parent,
stepparent, or adoptive parent.
24 Enter an ”X” in one box only to show your
relationship to the employee.

Page 3

Day

Year

 Yes
 No
 Natural Parent
 Stepparent

Go to Item 29

 Adoptive Parent

Go to Item 26

Go to Item 25

Form AA-20 (xx-xx)

StepParent

25 Enter the date of your marriage to the employee’s
natural mother or father.

Adoptive
Parent

26 Enter the place (city and state or foreign country)
where you adopted the employee.

Month

Day

Year

Go to Item 29

Month

Day

Year

27 Enter the date of the adoption.
28 Enter the name of the court which issued the
adoption decree.
Support

29 Enter an “X” in the appropriate box:
The employee was contributing at least one-half of the money and
goods needed to support me at the time the employee died or at
the beginning of the employee’s period of disability if he or she
had one. (Consider the following as contributions to support:
money, food, clothes, paying bills, providing rent-free housing.)

 Yes
 No

Go to Note and Item 30
Go to Section 11

Note: If answered “Yes,” you will have to complete and return to the RRB,
Form G-134, Statement Regarding Contributions and Support.
Marriage

 Yes
 No

30 Enter an “X” in the appropriate box:
I remarried after the employee’s death.

Go to Item 31
Go to Item 32

31 Enter the requested information for each of your marriages after the employee’s death. Print the most recent
marriage in a, the second most recent in b, and so on.
How Marriage Ended
(Check One)
Date
Married

Your Husband’s or
Wife’s Name

a

Month

b

Month

c

Social
Security
Number
Criminal
Offense

Month

(If Marriage Never Ended
Leave Blank)

Day

Year

Day

Year

Day

Year











Spouse’s death
Divorce
Annulment
Spouse’s death
Divorce
Annulment
Spouse’s death
Divorce
Annulment

32 Enter your social security number.
If none enter “TO BE SUBMITTED.”
33 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.
34 Enter the date of the conviction.

35 Enter the date of the sentence of confinement.
Form AA-20 (xx-xx)

Page 4

 Yes
 No

Go to Item 34
Go to Section 6

Month

Day

Year

Month

Day

Year

Criminal
36 Enter the date that confinement began.
Offense
(Continued)

Month

 Yes
 No

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

Month

38 Enter the date confinement ended.

Section 6
Social
Security
Benefits

Day

Year

Go to Item 38
Go to Section 6

Day

Year

Information About Applicant’s Other Government Benefits

39 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 40

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

 Yes
 No

Go to Item 41

43 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 someone other
than the employee.

 Yes
 No

Go to Item 44

44 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 7

Go to Item 43

Go to Item 43

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

Go to Section 7

Go to Item 45

45 Enter the name of the person on whose record
you have filed or will file.
46 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 Part V of the RB-17 booklet to find out how work and earnings
can affect your railroad retirement annuity.
If you were age full retirement age or older when the employee died, or you are now full retirement age or older, go to Item 57,
Railroad Work.
When answering Items 47 through 56, refer to Form G-77, How the Amount of Earnings Affects Payment of Survivor
Annuities, for the exempt amount to use.
If the employee died January 1 or later of this year, skip Items 47-50 and go to Item 51, Earnings This Year.
Earnings
Last Year

47 Enter an “X” in the appropriate box:
My total earnings for all employment last year
were more than the annual earnings exempt
_________
(Year)
amount shown on Form G-77.

 Yes
 No

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

$

49 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

Page 5

Go to Item 48
Go to Item 51

Go to Item 51
Go to Item 50
Form AA-20 (xx-xx)

Earnings
50 Enter an “X” next to each month last year in which you did
Last Year
not earn more than the monthly earnings exempt amount
(Continued)

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

or perform substantial services in self-employment.

Earnings
This Year

51 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.
_________

 Yes
 No

Go to Item 52
Go to Item 55

(Year)

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

$

53 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.

 Yes
 No

54 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.

Earnings
Next Year

55 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.

Go to Item 55
Go to Item 54

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

 Yes
 No

Go to Item 56
Go to Item 57

(Year)

Railroad
Work

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

$

57 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 58
Go to Section 8

58 Enter the name of your last railroad employer.

59 Enter the date you last worked for this employer.

60 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 61 only if you expect your annuity to begin before January 1 of this year.
61 Enter an “X” next to each month of last year
during which you worked for an employer in
the railroad industry.

Form AA-20 (xx-xx)

Page 6

Section 8
Filing
Protection

Filing Date And Medicare

Answer Item 62 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.
62 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.

 Yes
 No

63 Enter an “X” in the appropriate box:
I am enrolled in the Medicare medical insurance (Part B).

Go to Item 64
Go to Item 66

64 Enter the name of the agency where you have filed for Medicare.
65 Enter your Medicare claim number.
Go To Section 9
66 Enter an “X” in the appropriate box:
I am 64 years and 5 months of age or older.

 Yes
 No

Go to Item 67

67 Enter an “X” in the appropriate box:
I wish to enroll in Part B.

 Yes
 No

Go to Item 68

68 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

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

 Yes
 No

Section 9

Go to Section 9

Go to 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

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



Direct Deposit - Go to Item 71



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 71 through 75 below.

71 Enter the name of your financial institution.
Area Code

72 Enter the telephone number
for your financial institution.

Telephone Number

73 Enter the routing transit number of your
financial institution.
Page 7

Form AA-20 (xx-xx)

Direct
Deposit

74 Enter your account number.
75 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

76 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-20 (xx-x)

Page 8

Section 11

Certification

Certification 77 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 78
Go to Item 78

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.
78 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 marry;
• If I file for social security benefits based on any person’s earnings record;
• If I go to work for a railroad, railroad labor orgaization 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
79

If this certification is signed by mark (“X”) in Item 78, 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 9

Form AA-20 (xx-xx)

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 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-20 (xx-xx)

Page 10