Form RL-94F (03-13) RL-94F (03-13) Survivor Questionnaire

UNITED STATES OF AMERICA

RAILROAD RETIREMENT BOARD

CURRENT

WWW.RRB.GOV
OFFICE HOURS: 9:00 AM TO 3:30 PM
MONDAY THROUGH FRIDAY EXCEPT FEDERAL HOLIDAYS

TOLL-FREE NUMBER: 1-877-772-5772

,
In reply refer to
Name of Deceased Railroad Employee
Name of Deceased Annuitant

To assist us in determining whether there are any benefits payable under the Railroad Retirement
Act due to the death of the person named above, please complete the enclosed questionnaire
and return it using the enclosed envelope. If you do not know the answer to an item, write
"Unknown" in that item.
If the person was receiving an annuity under the Railroad Retirement Act, the annuity is not
payable for the month in which the annuitant died. Annuity checks are dated the first of the month
and cover payment for the previous month. If you receive a check(s) for any month(s) for which
the person should not be paid, you should return it to the:
Department of the Treasury
Philadelphia Financial Center
P.O. Box 51319
Philadelphia, PA 19115-6319

or

RRB field office
at address shown above

If the person was enrolled in Direct Deposit, notify the financial institution to return all payments
that are received after the date of death.
This is not an application for benefits. If benefits are payable, the eligible person(s) will be
required to file an application.
Special Instructions
If there is an "X" in this box, complete only Sections 4 and 6.
Sincerely,

Enclosure

Form RL-94F (03-13)

Page 1

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0032

Survivor Questionnaire
Section 7(b) of the Railroad Retirement Act (RRA) of 1974 authorizes the U.S. Railroad Retirement Board to gather
information and records needed to assure proper administration of the RRA. The information obtained from this
questionnaire will be used for determining whether benefits are payable under the RRA. Although you are not required
to furnish this information which is necessary to determine eligibility for benefits, if you fail to do so, nonpayment of
benefits may result.
We estimate this form takes an average of 10 minutes per response to complete, including the time needed 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 aspect of this form,
including suggestions for reducing completion time, to Chief of Information Resources Management, Railroad
Retirement Board, 844 North Rush Street, Chicago, Illinois 60611-2092.

Instructions
Type or print legibly in ink. If you need more space than is provided to answer a question, continue in Section 5. If
you do not know the answer to a question, print "Unknown" in the space provided for the answer.
Some items on this questionnaire 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. Follow the instructions that tell you to "Go to" another item.
These are designed to save you time and help you move through the questionnaire quickly. If no "Go to" instructions
are given, answer the next item in order. Do not skip any items unless directed to do so.

Section 1

Identifying Information

Check the information entered by the Railroad Retirement Board (RRB) for Items 1 through 4 for accuracy.
 If the information is correct, go to Section 2.
 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.
1

Deceased Employee's Name

2

Place of Death (City and State)

3

Date of Birth

Section 2

4 Date of Death

Information About Employee's Work Services and Family
From
Day

To
Day

5

If the employee was ever in active military service enter
the dates of service, otherwise go to Item 6.


6

Furnish the following information regarding the employee's employment after stopping work in the railroad
industry. (Include any part-time work. If the employee worked for him/herself, write "self-employed" in the first
column.)
Began
Ended
Name and Address of Employer
Month
Year
Month
Year

Month

Year

Month

Year

Form RL-94F (03-13)

Page 2
7

Was the employee survived by a widow(er) or a remarried
(Check one) 
widow(er)?
a Widow(er)'s Name, Address, and Telephone Number
Name

Yes - Complete a-e, below
No - Go to Item 8

_________________________________________________________________________________

Address _________________________________________________________________________________
_________________________________________________________________________________
Telephone Number (Include area code) ________________________________________________________
b

Widow(er)'s Date of Birth

c Widow(er)'s Date of Marriage to Employee

Is the widow(er) disabled for all regular employment? (Check one) 
Were the employee and widow(er) living together at
(Check one) 
the same address at the time of the employee's death?
Was the employee survived by a divorced spouse to
whom he or she was married at least 10 years or who has (Check one) 
children of the employee in his or her care?
a Divorced Spouse's Name, Address, and Telephone Number
d
e

8

Name

Yes

No

Yes

No

Yes - Complete a-d, below
No - Go to Item 9

_________________________________________________________________________________

Address _________________________________________________________________________________
_________________________________________________________________________________
Telephone Number (Include area code) ________________________________________________________
b

Divorced Spouse's Date of Birth

d
9

10

Is the divorced spouse disabled for all regular
employment?
Was the employee survived by:
a unmarried children under age 18? (Includes a
natural child, stepchild, adopted child, or
dependent grandchild.)
b unmarried children who have been continuously
disabled since before age 22?
c unmarried children age 18-19 who are full-time
students at an elementary or high school?
d a parent age 60 or over who was dependent on
the employee for at least one-half support?
Enter all survivors for whom "Yes" is indicated in Item 9.
Name, Address, and Telephone Number

c Divorced Spouse's Date of Marriage to Employee

(Check one) 

Yes
No

(Check one) 

Yes
No

Yes
No
Yes
(Check one) 
No
Yes
(Check one) 
No
If more space is needed, continue in Section 5.
(Check one) 

Month

Date of Birth
Day
Year

Relationship
To Employee

Form RL-94F (03-13)

Page 3

Information About Employee's Burial Expenses and Estate

Section 3

Complete Items 11 through 15 only if the employee was not survived by a widow(er) who was living with the employee
at the time of death. If there is more than one executor or payer of the burial expenses, etc., provide their name,
address and telephone number in Section 5, Remarks.
11 Name, Address, and Telephone Number of the funeral director who buried the employee.
Name

____________________________________________________________________________________

Address ____________________________________________________________________________________
____________________________________________________________________________________
Telephone Number (Include area code) ___________________________________________________________
12

Name, Address, and Telephone Number of the person who paid or will pay the burial expenses.
Name

____________________________________________________________________________________

Address ____________________________________________________________________________________
____________________________________________________________________________________
Telephone Number (Include area code) ___________________________________________________________
13

Have all of the burial expenses been paid?

(Check one) 

Yes
No

14

a. Did, or will, the payer of the burial expenses use his/her
own funds (including a joint account with the
(Check one) 
deceased)?
b. 1. Did, or will, the payer of the burial expenses use
the funds of the employee’s estate (including a
(Check one) 
trust agreement)?

Yes
No

Yes - If a Trust Agreement,
complete Item 14b.2
No - Go to Item 14c
2. Provide the name, address, and daytime telephone number of the Trustee(s). If more than one, continue
in Section 5, Remarks.
Name

_______________________________________________________________________________

Address _______________________________________________________________________________
_______________________________________________________________________________
Telephone Number (Include area code) ______________________________________________________
Yes - Explain below
c. Did, or will, the payer of the burial expenses use the
(Check one) 
funds of others?
No - Go to Item 15
Explanation:

15

a. Has a court appointed administrator or executor been
appointed, or expected to be appointed? Answer "No"
Yes - Complete Item 15b
(Check one) 
if someone has been named in the employee's will
No - Go to Section 4
only.
b. Court Appointed Administrator's Name, Address, Telephone Number and Date of Appointment
Name

__________________________________________________________________________________

Address __________________________________________________________________________________
__________________________________________________________________________________
Telephone Number (Include area code) _________________________________________________________
Date of Appointment ____________________________________________

Form RL-94F (03-13)

Page 4

Section 4
16

Section 5
17

Remarks

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.

Section 6
18

Information About Employee's Survivors

Give the information requested below about the employee's living relatives only if there are no survivors listed in
Item 10 or, if there is an "X" in the special instructions box on the first page of this form, give the information
requested below about the employee's Children. If no child survives, then the Grandchildren. If no grandchild
survives, then the Parents. If none of the preceding relatives survive, then the Brothers and Sisters (no date of
birth needed.)
Date of Birth
Relationship
Name, Address, and Telephone Number
to Employee
Month
Day
Year

Certification

I understand that giving fraudulent, false or incomplete information to the Railroad Retirement Board to cause
payment of benefits is a crime punishable by Federal law. I certify that the information that I have provided is true,
correct and complete to the best of my knowledge.
Signature of Person Furnishing Information
Relationship to Employee
Number and Street Address

Daytime Telephone Number

(
City, County, State and ZIP Code

Date 

)
Month

Day

Year

Form RL-94F (03-13)