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United States of America
Railroad Retirement Board
Form Approved
OMB No. 3220-0002
Do Not Write In This Space
OFFICIALLY FILED
MONTH
DAY
YEAR
OFFICE NUMBER
LAST ER
APPLICATION FOR
NEXT-TO -LAST ER
APPROVED
EMPLOYEE ANNUITY
DATE CODED
APPLICATION NUMBER
MONTH
DAY
YEAR
CODED BY
Section 1
General Instructions
Before you complete this application, be sure to read the booklet RB-1, Age and Service Employee Annuity, which explains
information you will need to answer many of the questions in this application. Also be sure to read the important notices in the
RB-1 booklet.
Type or print legibly in ink. If you need more space than is provided to answer a question, use Section 21 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, 2016 as:
MONTH
0
6
DAY
0
6
YEAR
2
0
1
6
Some items in this application will not apply to you and 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 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 5 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
1
Railroad Retirement Claim Number
3
Employee’s Name
4
Employee’s Street Address
2
Social Security Number
Zip Code
City and State/Province
5
a Daytime Telephone Number
(
)
Country
b Alternate Telephone Number
(
)
Form AA-1 (03-16) Destroy Prior Editions
Information About You and Your Family
Section 3
Sex
6
7
Enter your name at birth if different from Item 3.
Birthday
8
Enter your date of birth.
Marital
Status
9
Enter an “X” in the box that shows your
current marital status.
Current
Marriage
Previous
Marriage
History
Male
Female
Month
10
Enter your spouse’s full name before your marriage.
11
Enter your spouse’s date of birth.
12
Enter the date of your marriage.
13
Enter your spouse’s social security number.
If none, enter “To Be Submitted.”
14
Enter an “X” in the appropriate box:
I was previously married. (Answer “No” if your only
previous marriage was an earlier marriage to your
current spouse.)
15
Enter an “X” in the box that shows
your sex.
Day
Year
Never Married
Go to Item 16
Married or Separated
Go to Item 10
Other
Go to Item 14
Month
Day
Year
Month
Day
Year
Yes
Go to Item 15
No
Go to Item 16
Give the following information for your previous marriage(s). Use Section 21 if you have more than one previous
marriage.
(i) MARRIAGE BEGAN
a
DATE
CITY & STATE
(i i i ) MARRIAGE ENDED
( ii) NAME OF FORMER
SPOUSE
DATE
REASON
CITY & STATE
DEATH DIVORCE
ANNULMENT
OTHER - Explain in
Section 21
(iv) Enter your former spouse’s date of birth.
(v) Enter the Social Security Number of former spouse
shown in Section 15a(ii).
Month
Day
Year
If unknown, enter Unknown and complete Item 15b.
b Enter your former spouse’s
• Place of birth
Children
•
Father’s name
•
Mother’s maiden name
Please read Part I of the RB-1 booklet for an explanation of family members who could qualify you for the
Special Guaranty Computation.
16
Enter an “X” in the appropriate box:
I have children who are unmarried and meet any of the
following conditions:
(1) Under age 18.
(2) Age 18 through 19 and attending elementary or
secondary school full-time.
(3) Age 18 or older with a continuing disability that began
before age 22 and prevents any kind of employment.
Yes
Go to Note and Item 17
No
Go to Item 18
Note: If you have a child that meets the disability requirements, you may be asked to complete
Form AA-19a, Application for Determination of Child’s Disability.
17
Enter in each box the number
of children who meet each condition.
Under age 18.
18 through 19 and attending elementary
Age
or secondary school full-time.
Age 18 or older with a continuing disability
that began before age 22 and prevents any
kind of employment.
Form AA-1 (03-16) Page 2
Do not complete Item 18 if you have never married; go to Item 19.
Garnishment
or
Property
Settlement
Criminal
Offense
18
19
Enter an “X” in the appropriate box:
a. I am party to a court order to enforce either my child support
or alimony obligation, or to pay part of my present or future
railroad retirement benefit to a spouse or former spouse as
a part of a property settlement in a divorce or legal separation proceeding. (NOTE: Reference to pension rights may
be found in the property settlement.)
b. Which situation applies?
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.
20
Enter the date of the conviction.
21
Enter the date of the sentence of confinement.
22
Enter the date that confinement began.
23
Enter an “X” in the appropriate box:
Has the confinement ended?
24
Section 4
Enter the date confinement ended.
Yes
Go to Item 18b
No
Go to Item 19
Child Support or Alimony
Property Settlement
Yes
Go to Item 20
No
Go to Section 4
Month
Day
Year
Month
Day
Year
Month
Day
Year
Yes
Go to Item 24
No
Go to Section 4
Month
Day
Year
Information About Type of Annuity
Please read Part I of the RB-1 booklet for information about age and service annuities. Also read the RB-1d booklet if you are
applying for a disability annuity.
Type of
Annuity
25
26
Section 5
Enter an “X” in the box that shows the type
of annuity you are filing for.
Enter an “X” in the appropriate box:
I am eligible for and will accept a reduced age annuity
if I am not eligible for a full age or a disability annuity.
}
FULL AGE ANNUITY
FULL 60/30 AGE ANNUITY
DISABILITY ANNUITY
REDUCED AGE ANNUITY– LESS
THAN 30 YEARS SERVICE
Yes
Go to
Item 26
}
Go to
Section 5
No
Information About Military Service
Please read Part I of the RB-1 booklet for information about military service. Creditable military service is used to determine, in
part, your annuity eligibility. It can also be used in your annuity computation.
Military
Service
27
Enter an “X” in the appropriate box:
I was in active military service, such as the Army, Navy,
Air Force or Marines, of the United States.
Yes
Go to Note and Item 28
No
Go to Section 6
Note: If answered “Yes,” you must submit proof of your military service, such as your discharge
certificate or separation papers, as explained in the RB-1 booklet.
28
29
Enter an “X” in the appropriate box:
I had voluntary military service during the period June 15,
1948, through December 15, 1950.
Yes
Go to Item 29
No
Go to Item 30
Enter an “X” in the appropriate box:
I had nonrailroad earnings after leaving the military service
stated in Item 28 and before returning to the railroad.
Yes
No
Form AA-1 (03-16) Page 3
Section 6
Information About Your Railroad Work
Please read Part I of the RB-1 booklet to find out what railroad work is creditable. Creditable railroad work is used to
determine your annuity eligibility and is also used in the annuity computation.
Last Railroad 30
Employment
Enter the name of the railroad company or railroad
labor organization that last employed you.
31 Enter your payroll name and identification number for
that employer.
32
Enter your last job title for that employer.
33
Enter your last division or department and its location
for that employer.
34
Enter the dates you worked for that employer.
(If your railroad employment has not ended,
enter the last date you will work for that
employer in the “TO” date.)
35
36
Year
Enter an “X” in the appropriate box to indicate
the type of annuity you are filing for.
Go to Item 35d
Age Annuity
Go to Item 35b
Disability Annuity
b
Have you relinquished your seniority rights?
Yes
No
c
Enter the reason why you relinquished your
rights.
d
Enter the date you gave up or will give up
your seniority rights and all other rights to
work for the employer shown in Item 30.
Enter an “X” in the appropriate box:
I worked for another employer in the railroad industry
or a railroad labor organization this year or last year.
37
Enter the name of that employer.
38
Enter your payroll name and identification number for
that employer.
39
Enter your last job title for that employer.
40
Enter your last division or department and its
location for that employer.
41
TO
Month Day
a
Note: You are not required to relinquish your
rights for a disability annuity.
Other
Railroad
Employment
FROM
Month Day
Year
Enter the dates you worked for that employer.
(If your railroad employment has not ended,
enter the last date you will work for that
employer in the “TO” date.)
Form AA-1 (03-16) Page 4
Month
Day
Yes
No
Go to Item 35c
Go to Item 36
Year
Go to Item 37
Go to Item 43
FROM
Month Day
Year
TO
Month Day
Year
Other
Railroad
Employment
(Cont.)
42
a
Enter an “X” in the appropriate box to indicate
the type of annuity you are filing for.
Go to Item 42d
Age Annuity
Go to Item 42b
Disability Annuity
b
Have you relinquished your seniority rights?
Yes
No
Note: You are not required to relinquish your
rights for a disability annuity.
Railroad
Seniority
Rights
43
44
Section 7
c
Enter the reason why you relinquished your
rights.
d
Enter the date you gave up or will give up
your seniority rights and all other rights to
work for the employer shown in Item 30.
Enter an “X” in the appropriate box:
I still have seniority or other rights to work for a
railroad employer or railroad labor organization
not listed in Item 30 or Item 37.
Month
Day
Go to Item 42c
Go to Item 43
Year
Yes
Go to Item 44
No
Go to Section 7
Print the name of any employer indicated
in Item 43 with whom you still have rights
to return to work.
Information About Pay For Time Lost
Please read Part II of the RB-1 booklet to find out what payments can be creditable as pay for time lost.
Pay For
Time Lost
45
Enter an “X” in the appropriate box:
I received or expect to receive pay for
time lost from my last railroad employer.
Yes
Go to Note and Item 46
No
Go to Section 8
Note: If answered “Yes,” and you received an injury settlement or elected to receive “dismissal pay,”
enclose a copy of your settlement or election with your application. If your case is still pending, briefly
explain it in Section 21.
46
Section 8
Enter the dates for which
these payments were made or
will be made.
FROM
Month Day
Year
TO
Month Day
Year
Information About Railroad Sick Pay
Please read Part II of the RB-1 booklet to find out when sick payments can be creditable to Tier I.
Railroad
Sick Pay
47
Enter an “X” in the appropriate box: I received
or expect to receive sick pay under a railroad
wage continuation plan (other than my own
regular salary) that was established through
a company policy or labor agreement and
this pay was for a period after the actual day I
last worked. (Answer “No” if you were carried
on the payroll and just received your regular
salary.)
Yes
Go to Item 48a
No
Go to Section 9
48
a
Enter the name of the sick pay plan, if known.
b
Enter the dates for which these
payments were made or will be made
for up to 6 months after your actual day
last worked.
FROM
Month Day
Year
TO
Month Day
Year
Form AA-1 (03-16) Page 5
Section 9
Information About Your Nonrailroad Work
Please read Part IV of the RB-1 booklet, which explains how Last Pre-Retirement Nonrailroad Employment, self-employment,
and other earnings affect your annuity. Also read Part I of the booklet which explains “Current Connection.”
Nonrailroad
Work
49
Enter an “X” in the appropriate box:
I worked for pay outside the railroad industry
either during the last 6 months I worked in the
railroad industry or after I left the railroad industry.
(Do not include self-employment. Include any
employment for an incorporated business which
you own or public service. If you are a Canadian
citizen or permanent resident, include employment
in Canada for the U.S. railroad employer performed
January 1, 1983, or later.)
Yes
Go to Note and Item 50
No
Go to Item 60
Note: If you had Last Pre-Retirement Nonrailroad Employment (LPE) after your annuity would begin,
complete Form G-19F, Earnings Information Request, only when one of the following applies:
(1) The annuity beginning date (ABD) is before January 1 of this year or
(2) the ABD is January 1, or later, of this year, and you ceased working in LPE after the ABD month.
Most Recent
Railroad
Work
50
Enter the name and address of your current or most
recent nonrailroad employer.
51
Enter the Employer Identification Number (EIN)
for that employer.
52
Enter your average monthly salary for that employer.
(SHOW DOLLARS ONLY)
53
Enter the dates you worked for that
employer. (If you have not set the date
you expect to stop working, leave the
“TO” date blank and check the box
“I am still working.”)
54
Next Most
Recent
Nonrailroad
Work
Enter an “X” in the appropriate box:
The employer named in Item 50 is either a seasonal
employer or a Federal Government agency that is
listed in Chapter 5 of the RB-1 booklet.
55
Enter the name and address of your next most
recent nonrailroad employer during your last 6
months in the railroad industry or after you left
the railroad industry.
56
Enter the Employer Identification Number (EIN)
for that employer.
57
Enter your average monthly salary for that employer.
(SHOW DOLLARS ONLY)
58
59
Enter the dates you worked for that
employer. (If you have not set the date
you expect to stop working, leave the
“TO” date blank and check the box
“I am still working.”)
Enter an “X” in the appropriate box:
The employer named in Item 55 is either a seasonal
employer or a Federal Government agency that is
listed in Chapter 5 of the RB-1 booklet.
Form AA-1 (03-16) Page 6
$
FROM
Month Day
Year
TO
Month Day
Year
I am still working
Yes
No
If none, enter “NONE” and go to Item 60
$
FROM
Month Day
Year
I am still working
Yes
No
TO
Month Day
Year
SelfEmployment
If you are employed and your business is incorporated, answer Item 60 “No.” Make sure Items 49-59 are
completed instead. If your business is not incorporated, answer Item 60 “Yes” and go to Item 61.
60
Enter an “X” in the appropriate box:
I was self-employed during my last
6 months in the railroad industry or
after I left the railroad industry.
Yes
Go to Note and Item 61
No
Go to Section 10
Note: If answered “Yes,” complete and return to the RRB, Form AA-4, Self-Employment and
Substantial Service Questionnaire.
61
Enter an “X” in the appropriate box:
I am still self-employed.
Yes
Go to Section 10
No
Go to Item 62
MONTH
62
Section 10
DAY
YEAR
Enter the date you were last self-employed.
Deemed Current Connection
Please read Part I of the RB-1 booklet for an explanation of a deemed current connection.
Deemed
Current
Connection
63
64
65
66
Enter an “X” in the appropriate box:
I have at least 25 years of railroad service
and I have indicated nonrailroad employment
in Items 49-62 that could break my current
connection.
Yes
Go to Item 64
No
Go to Section 11
Enter an “X” in the appropriate box:
I was separated from my last railroad
employer involuntarily and through no fault
of my own on or after October 1, 1975.
Yes
Go to Item 66
No
Go to Item 65
Enter an “X” in the appropriate box:
I was on furlough, leave of absence or
absent because of injury status with my
last railroad employer on October 1, 1975,
and was never called back to work.
Yes
Go to Item 66
No
Go to Section 11
Enter an “X” in the appropriate box:
I declined an offer to work in the railroad
industry in the same “class or craft” as my
last railroad job.
Yes
Go to Section 11
No
Go to Note and Section 11
Note: If you answered either Item 64 or Item 65 “Yes” and Item 66 “No,” submit the required proofs as
soon as possible. This will preserve your rights under the deemed current connection provisions. The
required proofs are explained in the RB-1 booklet.
Section 11
Information About When Your Annuity Will Begin
Please read Part II of the RB-1 booklet for an explanation of an annuity beginning date.
Annuity
Beginning
Date
67
68
Enter an “X” in the appropriate box:
I want my annuity to begin on the
earliest date permitted by law.
Enter the date you want your annuity
to begin.
Yes
Go to Section 12
No
Go to Item 68
Month
Day
Year
Form AA-1 (03-16) Page 7
Section 12
Information About Your Earnings
Before answering Items 69-80, please read Part IV of the RB-1 booklet to find out how earnings can affect an age
and service annuity. For the exempt amounts, refer to Form G-77a, How Work Affects Your Railroad Retirement
Benefits.
If you are applying for a disability annuity but are eligible for and would accept a reduced age annuity if the disability
annuity is denied, answer Items 69-80, which apply to the reduced age annuity. Otherwise, go to Section 13.
Earnings
Last Year
69
__________
(Year)
70
Earnings
Last Year
(Cont.)
71
73
74
__________
(Year)
75
76
77
Earnings
Next Year
__________
(Year)
Yes
Go to Item 70
No
Go to Item 74
Enter an “X” in the appropriate box:
My total earnings from all employment last year were
more than the annual earnings exempt amount. (If all
your earnings are from only railroad employment before
your date last worked, answer “No.”)
Yes
Go to Item 71
No
Go to Item 74
Yes
Go to Item 74
No
Go to Item 73
Enter your total earnings for last year.
(SHOW DOLLARS ONLY)
__________ 72
(Year)
Earnings
This Year
Enter an “X” in the appropriate box:
I expect my annuity to begin before
January 1 of this year.
78
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.
Enter an “X” next to each month last year
in which you did not earn more than the monthly
earnings exempt amount or perform substantial
services in self-employment.
Enter an “X” in the appropriate box:
I expect my total earnings from all employment this year
to be more than the annual earnings exempt amount. (If
all your earnings are from only railroad employment before
your date last worked, answer “No.”)
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
Yes
Go to Item 75
No
Go to Item 78
Yes
Go to Item 78
No
Go to Item 77
Enter the total amount you expect to earn this year.
(SHOW DOLLARS ONLY)
$
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.
Enter an “X” next to each month this year in which
you did not earn, or do not expect to earn, more than
the monthly earnings exempt amount or perform
substantial services in self-employment.
Enter an “X” in the appropriate box:
I expect my total earnings from all employment next year to
be more than this year’s annual earnings exempt amount.
79 Enter the total amount that you expect to
earn next year. (SHOW DOLLARS ONLY)
80
$
Enter an “X” next to each of the first four
months of next year in which you expect to
earn less than this year’s monthly earnings
exempt amount.
Form AA-1 (03-16) Page 8
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
Yes
Go to Item 79
No
Go to Section 13
$
JAN
FEB
MAR
APR
Section 13
Information About Social Security Benefits
Please read Part V of the RB-1 booklet to see how this application can protect your rights to social security benefits, and
to see what effect your receipt of social security benefits will have upon your railroad retirement annuity.
Social
Security
Filing Date
81
82
Enter an “X” in the appropriate box:
I also want this application used to protect my filing
date for social security benefits. (Answer “Yes” 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.)
Yes
Enter an “X” in the appropriate box:
I have filed, or plan to file within the next 90 days,
an application for social security benefits.
Yes
Go to Item 83
No
Go to Section 14
Month
83
Enter the date you became, or will become, eligible
for these social security benefits.
84
Enter an “X” in the appropriate box:
I have received my first social security payment.
Enter the current total monthly amount of your
social security benefits (before reduction for
work or Medicare premiums).
$
Enter an “X” in the appropriate box:
All or part of my social security benefits described above are
based on the earnings of someone other than myself.
85
86
87
Enter the social security number of the person on whose
earnings your social security benefits are based.
88
Enter the name of the person on whose earnings your
social security benefits are based.
Section 14
No
Year
Yes
Go to Item 85
No
Go to Item 86
Yes
Go to Item 87
No
Go to Section 14
Information About Non-Covered Service Pension
Please read Part V of the RB-1 booklet for information concerning non-covered service pensions.
Non-Covered 89
Service
Pension
90
Enter an “X” in the appropriate box:
I am receiving or expect to receive a pension or annuity
or lump sum in excess of contributions based on any
work after 1956 not covered by social security or
railroad retirement.
Yes
Go to Item 90
No
Go to Section 15
Enter an “X” in the appropriate box:
The beginning date of the pension or
annuity is January 1, 1986, or later.
Yes
Go to Note and Section 15
No
Go to Section 15
Note: If answered “Yes,” complete Form G-209, Employee Non-Covered Service Pension
Questionnaire.
Form AA-1 (03-16) Page 9
Section 15
Information About Other Railroad Retirement Annuity
Please read Part V of the RB-1 booklet for an explanation of the effect of your employee annuity on any other railroad
retirement annuity.
Other
Railroad
Annuity
91
Enter an “X” in the appropriate box:
I have filed within the last 30 days, or intend to file
within the next 90 days, for an annuity based on
another person’s railroad earnings record.
92
Enter the full name of that other person.
93
Enter that other person’s railroad
retirement claim number, including the
letter prefix.
Section 16
Yes
Go to Item 92
No
Go to Section 16
Prefix
If only six numbers, enter here
Information About Private Pensions
Please read Part I of the RB-1 booklet for an explanation of what is required to be eligible for a supplemental annuity.
Supplemental 94
Annuity
Eligibility
Enter an “X” in the appropriate box:
I am receiving, or expect to receive, a monthly
pension or lump-sum pension payment from one
or more former railroad employers.
95
Enter the name of the last railroad employer
with whom you still hold pension rights.
96
Enter an “X” in the box which most accurately
applies to the job or position which qualified
you for this pension.
97
Enter the date your pension began, or will begin, or
the date of your lump-sum pension payment.
98
Enter the name of the second to last railroad employer
with whom you still hold pension rights. (If this employer is now part of the employer in Item 95, leave this
item blank and go to Item 101.)
99
Enter an “X” in the box which most accurately
applies to the job or position which qualified
you for this pension.
Yes
Go to Item 95
No
Go to Section 17
Salaried
Non-Agreement
Agreement
Other
Day
Month
Year
If none, enter “NONE” and go to Item 101
100 Enter the date your second pension began, or will begin,
or the date of your lump-sum pension payment.
101 Enter an “X” in the appropriate box:
The pension named in Item 95 or Item 98
is based on a collective bargaining (union)
agreement.
Form AA-1 (03-16) Page 10
Salaried
Non-Agreement
Agreement
Other
Month
Day
Yes
No
Year
Section 17
Information About Medicare
Complete this section only if you are 64 years and 5 months of age or older.
Please read Part VI of the RB-1 booklet for an explanation of the Medicare program.
Medicare
Enrollment
102 Enter an “X” in the appropriate box:
I have a Medicare card that shows entitlement
to Medicare medical insurance (Part B).
Yes
Go to Item 103
No
Go to Item 104
103 Enter your Medicare claim number.
(If this is a railroad retirement filing, enter the prefix. If this
is a social security filing, enter the suffix).
Go to Section 18
104 Enter an “X” in the appropriate box:
I have filed for Part B within the last 3
months.
Enter the social security number or railroad retirement
claim number under which you filed.
(If this is a railroad retirement filing, enter the prefix. If
105 this is a social security filing, enter the suffix.)
Prefix
Yes
Go to Item 105
No
Go to Item 106
Month
If only six numbers, enter here
Day
Year
Date of filing
Go to Section 18
106 Enter an “X” in the appropriate box:
I wish to enroll in Part B.
Yes
If you are under age 65 years
and 4 months, Go to Section 18.
If you are older than age 65 years and 3
months, Go to Item 107.
No
I understand that I elected not to
enroll in Part B and that the premium rate
may be higher if I do enroll later in Part B.
Go to Section 18.
107 Enter an “X” in the appropriate box:
I am currently covered by an employer group health
plan (EGHP) based on my own or my spouse’s
current employment.
Yes
Go to Item 109
No
Go to Item 108
108 Enter an “X” in the appropriate box:
I was previously covered by an EGHP based on my
own or my spouse’s current employment.
Yes
Go to Item 110
No
Go to Section 18
109
The beginning date of my EGHP coverage is:
If applicable, the date employment will stop for the
person whose employment qualifies me for EGHP
coverage is:
110 The beginning and ending
dates of my EGHP covEGHP Beginning Date
erage and the date last
worked in the employment EGHP Ending Date
which qualified me for
Date Employment Stopped
EGHP coverage are:
111
Enter an “X” in the appropriate box:
I wish to enroll in a special enrollment period.
Month
Day
Year
Month
Day
Year
Go to Item 111
Month
Day
Year
Go to Item 111
Yes
Go to Item 112
No
Go to Item 113
Form AA-1 (03-16) Page 11
Medicare
Enrollment
(Cont.)
112 Enter an “X” in the appropriate box:
a. I am enrolling in Part B while either still covered
by an EGHP or during the first full month after
my EGHP coverage.
b. I am requesting a Part B effective date of
Yes
No
Month
Go to Item 112b
Go to Section 18
Day
Year
Go to Section 18
113 Enter an “X” in the appropriate box:
I am requesting premium surcharge relief for
the months of EGHP coverage.
Section 18
Yes
No
Disability Medicare
If you are filing for a disability annuity, go to Section 19.
If you are less than 64 years and 5 months of age, and you are not filing for a disability annuity, you may be entitled to
Medicare benefits based on your being totally disabled for all employment and being entitled to an annuity before age 63.
If your entitlement begins after age 63, you may not be entitled to early Medicare, but you may be entitled to have your
Tier I benefit treated as a social security benefit for taxation purposes. See Form TB-85, Information About the Taxation
of Railroad Retirement Annuities, Part 6, Section 6A.
Disability
Medicare
114 Enter an “X” in the appropriate box:
I expect my annuity to begin before I
reach age 63.
Yes
Go to Item 115
No
Go to Section 19
115 Enter an “X” in the appropriate box:
I am totally disabled for work in all
regular employment.
Yes
Go to Note and Section 19
No
Go to Section 19
Note: If answered “Yes,” complete and return Form AA-1d, Application for Determination
of Employee’s Disability, to apply for Medicare based on disability.
Section 19
Information About You If You Are Disabled
Answer Items 116-118 ONLY if you are applying for a disability annuity. Otherwise, go to Section 20. If you are applying
for a disability annuity, also complete and return Form AA-1d, Application for Determination of Employee’s Disability.
You are asked about your children to determine if you are entitled to a special annuity computation.
Please read Part V of the RB-1 booklet for an explanation of worker’s compensation benefits and public disability benefits.
Child Living
With You
116 Enter an “X” in the appropriate box:
I had living with me at least one of my
own or my spouse’s children, who was
under age 3.
Worker’s
117 Enter an “X” in the appropriate box:
Compensation
Since my disability began, I have
received, or expect to receive,
worker’s compensation benefits.
Yes
Yes
Go to Note and Item 118
No
Go to Item 118
No
Note: If answered “Yes,” proof of the amount(s) and effective date(s) of your worker’s
compensation benefit is required.
Form AA-1 (03-16) Page 12
Public
Disability
Benefits
118 Enter an “X” in the appropriate box:
Since my disability began, I have
received, or expect to receive, disability
benefits under a Federal, state, or local
government plan or law.
(Answer “No” if your benefits are social
security, veterans affairs, or welfare.)
Yes
Go to Note and Section 20
No
Go to Section 20
Note: If answered “Yes,” proof of the amount(s) and effective date(s) of your public disability
benefit is required.
Section 20
Receiving Your Payments
All applicants filing for RRB benefits must choose to receive their 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-1 booklet for an explanation of Direct Deposit and the Direct Express® Debit MasterCard®.
Payment
Options
119 Enter an “X” in the appropriate box to indicate how you
want to receive your payments.
Direct Deposit - Go to Item 120
Direct Express® Debit MasterCard®
Go to Section 21
Neither Direct Deposit nor Direct Express®
Debit MasterCard® - Go to Section 21
Direct
Deposit
To provide the information we need to correctly deposit your payments by Direct Deposit, either attach a voided
personal check and go to Section 21, or call your financial institution for the information you need to complete
Items 120 through 124.
120 Enter the name of your financial institution.
121 Enter the telephone number of your
financial institution.
Area Code
Telephone Number
122 Enter your routing transit number of your financial institution.
123
Enter your account number.
124 Enter an “X” in the appropriate box:
Type of account for the above account number.
Checking
Savings
Form AA-1 (03-16) Page 13
Section 21
Remarks
Remarks
125 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-1 (03-16) Page 14
Section 22
Certification
Certification
126 Enter an “X” in the appropriate box:
I will have a guardian or other representative
sign this application on my behalf.
YES
Go to Note and Item 127
NO
Go to Item 127
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.
127
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-1, Age and Service Employee Annuity and RB-9, Employee and Spouse Annuities-Events That Must
be Reported. 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 receive a lump-sum or begin to receive a pension
based on earnings that are not covered by
the Social Security Administration (SSA) or the
RRB.
•
IF I begin to receive benefits directly from SSA.
•
IF I am disabled and begin to receive worker’s
compensation or public disability benefits.
•
IF I receive a lump-sum payment or begin to receive
a monthly pension from my last previous railroad
employer.
•
IF I am entitled to a vested dual benefit and begin to
receive a benefit based on military service performed
before 1957.
•
IF I return to work for a railroad or railroad labor
organization, or return to work in any capacity in the
railroad industry.
•
IF I return to work for my Last Pre-Retirement
Nonrailroad Employer or there is a change in my
estimated earnings.
•
IF I am filing in advance of the date(s) shown in item(s)
34 (and 41), and there is a change in a date.
•
IF I receive a settlement with credit for railroad service
as “pay-for-time-lost for months after the date(s) shown
in item(s) 34 (and 41).
•
•
•
•
•
•
•
•
•
•
IF benefits I receive directly from SSA are adjusted for a
reason other than normal cost-of-living increases.
IF my address changes.
IF my financial organization or the account number at
my financial organization changes.
IF I am confined in a jail, prison, penal institution, or
correctional facility due to a conviction for a criminal
offense.
IF I earn more than the annual earnings exempt
amount.
IF I perform work, including self-employment, for a family
owned, controlled or managed business, including a
business operated, managed or owned by me, 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.).
IF my spouse who is receiving a benefit dies, or our
marriage ends in divorce or annulment.
IF a qualifying child marries or leaves my custody or
residence.
IF I 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.
IF I receive anything of value in lieu of salary or
wages for any work that I performed.
Also, if I am covered by the earnings restriction provisions of the Railroad Retirement Act, I have received and reviewed
Form G-77a, How Work Affects Your Railroad Retirement Benefits. Failure to report any of the above events or other
events that may effect my annuity may result in a penalty deduction from my annuity, criminal and/or civil prosecution.
SIGNATURE
(First Name, Middle Initial,
Last Name)
Month
Day
Year
DATE
128 If this certification is signed by mark (“X”) in Item 127, two witnesses who know the person signing must
sign below, giving their full addresses and daytime telephone numbers.
a. Signature of Witness
b. Signature of Witness
Address (Number and Street)
Address (Number and Street)
City, State, ZIP Code
City, State, ZIP Code
Area Code
(
Telephone Number
)
Area Code
(
Telephone Number
)
Form AA-1 (03-16) Page 15
Section 23
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-1 (03-16) Page 16
| File Type | application/pdf |
| File Title | AA-1 XX-XX.indd |
| Author | KINGSLA |
| File Modified | 2016-09-13 |
| File Created | 2016-03-16 |