Form AA-5 (01-04)

United States of America
Railroad Retirement Board

Form Approved
OMB NO. 3220-0052

RRB claim number

Application for
Substitution
of Payee

Employee's SS number
Employee's name
Beneficiary's name

1

Field office name
and number
Before you complete this application, be sure to read Booklet RB-5, Your Duties As Representative PayeeIRepresentative Payee's
Record, and the "Important Notices" on page 8 of this application. This application must be completed by the person filing to act as the
representativefor the beneficiary.
1

Enter the applicant's name, address, and daytime telephone number.
(Include Number and Street, P.O. Box or Rural Route, City, State, and ZIP Code.)

Telephone Number

,

2

Enter the applicant's Social Security number.
Note: If filing as an administrator of an institution,
enter your Employer Identification Number (EIN).

3

Are you the court appointed legal representative of the beneficiary?
Yes - Attach a copy of the court order and go to ltem 4
No - Go to ltem 5
Is the court order currently in effect?
Yes - Go to ltem 7
No - Explain in ltem 17 and go to ltem 5
Is there a court appointed legal representative whose court order is currently in effect?
Yes - Go to ltem 6
No - Go to ltem 7
Enter the legal representative's name, full address, and daytime telephone number.
(Include Number and Street, P.0. Box or Rural Route, City, State, and ZIP Code.)

4

5

6

a

a
a
a
a

I
7

8

Teleohone Number

I

Does the beneficiary live with you?
Yes - Go to ltem 10
No - Go to ltem 8
Enter the name, full address, and daytime telephone number of the person or institution with whom the beneficiary
is living. (Include Number and Street, P.O. Box or Rural Route, City, State, And ZIP Code.)

a
a

I

Telephone Number

Form AA-5 (01-04) Destroy Prior Editions

9

What is the relationship between the beneficiary and the person with whom the beneficiary is living?
Spouse
Relative (speciQ relationship)
Legal Guardian
Other

a

a

10 What is your relationship to the beneficiary? (Check all that apply.)
Spouse
Relative (speciQ relationship)
Legal Guardian - Go to ltem 12
Other

a

11 a Are there any living relatives who are more closely related to the beneficiary than you are?

a Yes - Complete ltem I 1b

0

No - Go to ltem 12

b Enter the name, address, and daytime telephone number of each living relative who is more closely related to
the beneficiary than you. Also show their relationship (parent, child, brother, sister, etc.) to the beneficiary. If
more space is needed, go to ltem 17.

(1)

Telephone Number

Relationship

Telephone Number

Relationship

Note: If youare filing as an administrator of an institution, go directly to Item 14.
12 Are you currently employed?

Yes - Complete ltem 12a
No - Complete ltem 12b

a Enter your employer's name and address.

b Enter your main source of income.

a Self-employed
a Social Security benefits
a Pension
a SSl payments

Form AA-5 (01-04) Page 2

a Railroad Retirement benefits
a Welfare benefits
a Other (Describe)

13

Have you previously served, or applied and were not selected to serve, as a representative payee for the
beneficiary of a Federal benefit?

a Yes - Complete ltems l3a-c
a No - Go to ltem 14

a Enter the name of the beneficiary
b Enter the Social Security number
of the beneficiaw

c Enter the reason the service
ended.

-

I

14 Have you been convicted of a felony within the last 15 years?

a Yes - Complete ltems 14a-e
0

No-Gotoltem15

a What was the crime?
b On what date were you convicted?

c What was your sentence?
d If imprisoned, when were you

released?
e If probation was ordered, when
did or will your probation end?

15 Have you been convicted of a misdemeanor under the statutes administered by the Railroad Retirement
Board or Social Security Administration within the past 15 years?

a Yes - Complete ltems 15a-e
a No - Go to ltem 16
a What was the crime?
b On what date were you convicted?

c What was your sentence?
d If imprisoned, when were you
released?

e If probation was ordered, when
did or will your probation end?
16

a Why do you believe that you are the best qualified person to receive benefits on behalf of the beneficiary?

b Please explain how you intend to use the benefits.

Form AA-5 (01-04) Page 3

17 Remarks -Use this section to continue 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.

Instructions for Obtaining Form 6-478, "Statement Regarding Patient's Capability to Manage Benefits."
Depending upon the information furnished in Form AA-5, this additional form may be required.

Form G-478 is required if no guardian or legal representative has been appointed.
Form G-478 is completed either by the beneficiary's personal physician or by the medical officer of the institution
where the beneficiary resides.
Instructions on Information Booklets. You are being provided two or more booklets for your information and use:

The duties and responsibilities of a representative payee are explained in Booklet RE-5, "Your Duties as
Representative PayeelRepresentativePayee's Record." This booklet should be used to maintain a record
of income received and expenditures made for the beneficiary.
The other booklet(s) explains the conditions under which the annuity is not payable, and changes or events
affecting the beneficiary that are to be reported to the RRB.
After you have read the booklets and the Certification on the next page, sign Form AA-5. Form AA-5 (and when
required, Form G-478) should be returned to:

Form AA-5 (01-04) Page 4

18 Certification - I understand that civil and criminal penalties may be imposed on me for false or fraudulent
statements or for withholding information to misrepresent a fact material to determining a right to payment
under the Railroad Retirement Act. I affirm that, to the best of my knowledge, the information which I have
given is true, complete, and correct.
I have received Booklet RB-5, Your Duties as Representative PayeeRepresentative Payee's Record. I understand
that this booklet is to be used to maintain a record of income received and expenditures made for the beneficiary.
I agree to use all payments made to me on behalf of the beneficiary in the beneficiary's interest.

I agree to immediately notify the RRB:
If the beneficiary is restored to competency by a state court;
If the beneficiary marries, remarries, or divorces;
If I am discharged as the legal guardian;
If a legal guardian is appointed or guardianship changes;
If I am no longer responsible for the beneficiary's care and welfare;
If I have been convicted of a felony;
If I have been convicted of a misdemeanor under the statutes administered by the RRB or SSA;
If the beneficiary leaves my custody and care;
If my address changes;
If the beneficiary's address changes;
If the beneficiary performs any work, including self-employment;
If the beneficiary is convicted of a felony;
If the beneficiary begins to receive a public service pension, or there is a change in the amount of the
pension;
If an application for social security benefits is filed for the beneficiary on any person's earnings record;
If a student beneficiary graduates from high school or ceases full-time school attendance;
If the beneficiary is outside the U.S. for more than 30 consecutive days;
If the beneficiary dies.
Signature

-

-

(First Name, Middle Initial,
Last Name)
Date

-

II
Month

I

Day

I

Year

*u
I

19 If this certification is signed by mark ("X") in Item 18, 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
Daytime Telephone Number

-

b Signature of Witness

Address (Number and Street)
City, State, and ZIP Code
Daytime Telephone Number

Area Code

Telephone Number

Form AA-5 (01-04) Page 5

This Space Is For RRB Use Only
The evidence of incompetency of the beneficiary consists of:

a A legal document

A doctor's statement

a Other - Specify in Remarks below.

The applicant and beneficiary were interviewed in person.

a Yes

a No - Explain in Remarks below.

If Item 3 is answered "Yes," I verified that the applicant is the legal representative of the beneficiary and
that the court order is still in effect by:

a examination of a certified copy of the court order

personal contact with the court

I have verified the applicant's statement concerning previous representative payee appointment.

a Yes

Explain any discrepancies in Remarks below.

Form RB-5 was explained and furnished to the representative payee on
(Date)

The followirrg informational booklets were also provided to the representative payee:
I select the applicant as representative payee for the beneficiary.
yes

a No - Explain in Remarks below
Signature of selecting RRB representative

Signature of reviewing RRB representative

Remarks

Form AA-5 (01-04) Page 6

Receipt For Your Claim
Representative Payee ~ ~ ~ l i c a n~t a' sm e
Beneficiary's Name

Beneficiary's RRB Claim Number

Date Claim Received

Your application for substitution of payee has been received and will be processed as quickly as possible. If you change
your address, or if there is some other change that may affect your claim, you should report the change. The changes to
be reported are listed below. Always give us the beneficiary's claim number when writing or calling. If you have any
questions, we will be glad to help you. If you need to personally visit one of our field offices, please call for an appointment.
You will not be refused service if you do not have an appointment, but our staff can serve you better when an
appointment is made. Most offices are open to the public from 9:00 a.m. to 3:30 p.m., Monday through Friday.

Always Report These Changes To The RRB
Death-if the beneficiary dies.
Marital Status-If the beneficiary marries, remarries,
or divorces.
Social Security-If an application is filed for the
beneficiary on any person's earnings record.
Public Pension-If the beneficiary begins to receive
a pension from an agency of the Federal, state, or
local government, or if the amount changes.
Work-If the beneficiary performs any work, including
self-employment.
Felony and Misdemeanor-If you or the beneficiary
are convicted of a felony offense, or a misdemeanor
under the statutes administered by the RRB or SSA.

Address-If
changes

your address or the beneficiary's address

Legal Status-If there is any changes in the beneficiary's
competency or legal guardian (appointment, change, or
discharge).
In Your Care--If the beneficiary leaves your care or
custody.
School-If a student beneficiary graduates from high
school or ceases full-time school attendance.
Residency-If the beneficiary is outside the U.S. for
more than 30 consecutive days.

How To Report Changes
When a change occurs after you are entitled to receive benefits on behalf of the beneficiary, you should report the
change at once. You can make your reports by telephone, mail, or in person, whichever you prefer. Some telephone
reports may need to be confirmed in writing.

To report any of the above changes, contact:

Railroad Retirement Board

Telephone Number:
If for some reason you cannot contact that office, you should contact:

b

U S RAILROAD RETIREMENT BOARD
OFFICE OF PROGRAMS-OPERATIONS
844 N RUSH ST
CHICAGO IL 60611-2092
Form AA-5 (01-04) Page 7

Important Notices
Paperwork Reduction and Privacy Act Statement
This notice is given under the Paperwork Reduction Act of 1995 and the Privacy Act of 1974. The Privacy Act of
1974 requires that the Railroad Retirement Board (RRB) tell you the following whenever we ask you for information:

1) the law which allows us to ask for the information;
2) whether that law requires you to give us the information and what, if anything, might happen if you do not
give the information to us;
3) the reason why the information is requested; and
4) the persons, organizations and agencies to which we may release the information without your permission.
The RRB's authority for requesting this information is section 7 (b)(6)(45 U.S.C.231f(b)(6) of the Railroad
Retirement Act. The law does not give the RRB power to force you to give us information. However, if you do
not provide the information which we ask for, we may not be able to pay benefits to you.
The information which we ask you for is used to determine if you are eligible to receive benefits from the RRB.
Some of the information may have an effect on the amount of benefits which we can pay.
Although the information we request is almost never used for any purpose other than the payment of benefits
under the RRA, the RRB does have the authority to release information to the individuals, organizations, andlor
agencies listed below without your approval:

1) An attorney, Congressman's office, labor union or to the Department of State's embassy or consular
offices if they claim to be representing you at your request.
2) The U.S. Treasury Department or U.S. Postal Service to issue payments and to investigate lost, forged or
stolen checks.
3) The Social Security Administration to resolve discrepancies between appointed payees.
4) The Internal Revenue Service or to State and local taxing authorities for figuring your taxes and for use in
audits.

5) The Department of Justice for audits and for collecting overpayments owed to the RRB or the Social
Security Administration.

6) In certain cases information may be released for law enforcement purposes and for court proceedings.
A complete list of the persons, organizations or agencies to which the information you give us may be released
is available in any office of the RRB.
We estimate this form takes an average of 17 minutes per response to complete, including the time for reviewing
the instructions, getting the needed data, and reviewing the completed form. Federal agencies may not conduct or
sponsor, and respondents are not required to respond to a collection of information unless it displays a valid OMB
number. If you wish, send comments regarding the accuracy of our estimate or any other aspects of this form,
including suggestions for reducing completion time, to Chief of Information Resources Management, Railroad
Retirement Board, 844 N. Rush Street, Chicago, Illinois 6061 1-2092.

Form AA-5 (01-04) Page 8