AA-1sum (proposed) Application Summary

PROPOSED (COMPLETED)

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

APPLICATION SUMMARY FOR AN EMPLOYEE ANNUITY
RRB Claim Number
Name
Social Security Number

A 813-11-1920
Lance Carter
813-11-1920

The following information was either supplied by or verified by you in support of your application for
an Employee 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 and may be
punishable by fines, imprisonment or both.
Military Service
I was in active military service after September 7, 1939.
Recent Employment

I did not work for an employer outside the railroad industry in the last six months or since leaving
the railroad industry.
Railroad Employment

You have a current connection with the railroad industry.
I have worked for the following railroad, railroad labor organization or other employer in the railroad
industry.
Railroad Name
Date Last Worked
Date Rights Relinquished
Union Pacific Railroad
09/30/2011
09/30/2011
Name and Address

Daytime Telephone Number

Lance Carter
215 Backstreet Market
Marathon Fl 02202
219-201-8552

Date of Birth

08/28/1944

Type of Application Filed

Employee Annuity

RRB Form AA-1sum (xx-xx)

81311 19200 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

Application Filing Date

07/25/2011

I am applying for a benefit based on my age and railroad service.
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.
Marriages
I am currently married or separated.
Family
I do not have unmarried qualifying children.
Other Government Benefits
I am currently receiving a social security benefit.
I have not filed nor do I plan to file in the next three months for Social Security benefits on an
additional account number.
In the past month I have not filed nor do I plan to file in the next three months for Railroad
Retirement benefits on any other account number.
I am not receiving nor do I expect to receive a pension or lump-sum payment based on my earnings
after 1956 from an employer not covered by Social Security or Railroad Retirement.
Other Benefits
I expect to receive a railroad pension or lump-sum payment from Union Pacific Railroad.
Miscellaneous Information
The RRB has not been furnished with a court order to enforce my child support or alimony
obligation.
The RRB has not been furnished with a court order to pay part of my present or future railroad
retirement benefit to a spouse or former spouse as part of a property settlement in a divorce or legal
separation proceeding.
I have not received nor do I expect to receive pay for time lost from my last railroad employer.
RRB Form AA-1sum (xx-xx)

81311 19200 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

I have not received nor do I expect to receive sick pay under a wage continuation plan, established
through company policy or a labor agreement, for a period after the actual day I last worked.
Earnings Information
In 2012, I expect my total nonrailroad earnings will be less than $14,640.
Criminal Offense Information
Within the past 12 months I have not been imprisoned or been given a sentence of confinement due
to a conviction for a criminal offense.
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 wish to enroll in the Medicare Medical Insurance Plan (Part B).
Your application for an Employee Annuity has been released and will be processed as quickly as
possible. If you do not receive notification about your application by December 1, 2012 you should
contact the field office shown below.
You have received and reviewed the booklets RB-1, Age and Service Employee Annuity, and RB-9,
Employee and Spouse Annuities - Events that Must be Reported. It is your responsibility to report
events that would affect your annuity as explained in the booklets. Failure to report any of the
events listed below or other events that may affect your annuity may result in a penalty deduction
from your annuity, as well as 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.
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
Railroad Work – If you return to work for a railroad or railroad labor organization or return to
work in any capacity in the railroad industry.
Social Security – If you file for social security benefits based on any person’s earnings record.
RRB Form AA-1sum (xx-xx)

81311 19200 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

Social Security – If benefits you receive directly from the Social Security Administration are
adjusted for a reason other than normal cost-of-living increases.
Public Pension – If you receive a lump-sum or begin to receive a pension based on employment
not covered under the Social Security Act or Railroad Retirement Act.
Pension – If you receive a lump-sum payment or begin to receive a monthly pension from your
railroad employer.
Other Benefits – If you begin to receive worker’s compensation or a public disability benefit.
Settlement – If you receive a settlement with credit for railroad service as “pay-for-time-lost” for
months after 9/30/2011.
Employment – If you perform work, including self-employment, for a family owned, controlled or
managed business, including a business operated, managed or owned by you, a family member,
friend or close associate, whether for pay or not, and without regard to how the business is
organized (e.g., sole proprietorship, partnership, corporation, LLC, etc.).
Employment – If you become a corporate officer of, own or operate a corporation (including a
corporation owned by a family member or friend), whether for pay or not.
Employment – If you receive anything of value in lieu of salary or wages for any work that you
perform.
Earnings – If you work for any employer or perform any self-employment work.
Earnings – If your earnings change.
You told us you expect your total nonrailroad earnings for 2012 to be less than $14,640.
You are not earning more than $1,220.
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.
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.
Spouse – If your spouse who is receiving a benefit dies or your marriage ends in divorce or
annulment.
Child – If a qualifying child marries or leaves your custody or residence.
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:
RRB Form AA-1sum (xx-xx)

81311 19200 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

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.
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-1sum (xx-xx)

81311 19200 22000 06051 32704

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