Form AA-12 (10-10) AA-12 (10-10) Notice of Death and Request for Service Needed for Eligi

CURRENT

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0005
Section 1 – Identifying Information

NOTICE OF DEATH AND
REQUEST FOR
SERVICE NEEDED FOR ELIGIBILITY

1. Social Security No.

2. Railroad Name and Address

3. Name of Deceased Employee
4. BA No.

6. Date Last Worked

5. Payroll Number

or Paid for Time Lost

,
Facsimile Number:
7. Date of Birth

8. Date of Death

9. Date Released

Paperwork Reduction Act Notice
The Railroad Retirement Board's (RRB) authority for requesting this information is Section 7(b)(6) of the Railroad Retirement Act (45
U.S.C. 231f(b)(6)). The information requested is used by the RRB to determine a person’s eligibility for a survivor benefit under
Section 2 of the RRA (45 U.S.C. Sec. 231a).
We estimate this form takes an average of 5 minutes per response, 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 any comments regarding the
accuracy of our estimate or any other aspect of this form, including suggestions for reducing the completion time, to the Chief of
Information Resources Management, Railroad Retirement Board, 844 North Rush Street, Chicago, IL 60611-2092.

Section 2 - Employer Instructions
The survivor(s) of the deceased employee has filed for benefits under the Railroad Retirement Act (RRA). The applicant provided
the information shown in Items 6 and 8. Verification of the lag service is required for eligibility to the survivor benefit.
Complete Item 10 below only if the date in Item 6 differs from the date on your records.
Always complete Items 11 and 13.
Fax this form to (312) 751-7192 or mail it to the U.S. Railroad Retirement Board, Survivor Benefits Division, 844 North Rush
Street, Chicago IL 60611-2092, within 10 days of the date released by the RRB. The survivor cannot be awarded an annuity
until we receive this information.
IMPORTANT NOTE: This employee’s service months and compensation must also be included on your Form BA-3, Annual Report
of Creditable Compensation. Do not report service months after the date of death. If you have any questions, refer to the “Reporting
Instructions to Employers” or telephone the Quality Reporting Service Center at (312) 751-4992.
Month

10. Date Employee Last Worked or Paid for Time Lost on Your Records 

Day

Year

11. Indicate with an “X,” months the employee had service. The “Current Year” refers to the year shown in Item 6. “Prior Year” is
the year before. If this form will be submitted before your annual report for the prior year, complete items about the prior year
as well. Do not report service months after the date in Item 8.
J

F

M

A

M

J

J

A

S

O

N

D

TOTAL MONTHS

Current Year
Prior Year
12. REMARKS

Section 3 - Employer Certification
13. I understand that civil and criminal penalties can be imposed against 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 certify that,
to the best of my knowledge, the information which I have given is true, complete, and correct.
Signature of Certifying Officer

Date

Title of Certifying Officer

Telephone No.

(
Facsimile No.

(

)

E-Mail Address

)

Form AA-12 (10-10)