AA-1cert (Proposed Application Summary and Certification

United States of America
Railroad Retirement Board

PROPOSED (COMPLETED)

Form Approved
OMB 3220-0002

APPLICATION SUMMARY and CERTIFICATION 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. After you have
reviewed the information, make any changes on the summary, initial the change and sign
the certification on the last page. Return the certification and all pages of the summary to
the RRB.
Military Service
I was in active military service.
Recent Employment
I did not work for an employer outside the railroad industry during 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
02/29/2016
02/29/2016

Name and Address

Lance Carter
215 Backstreet Market
Marathon Fl 02202

Daytime Telephone Number
Alternate Telephone Number

219-201-8552
736-526-9875

Date of Birth

08/28/1946

Type of Application Filed

Employee Annuity

I am applying for a benefit based on my age and railroad service.

RRB Form AA-1cert (xx-xx)

81311 19200 22000 06051 32704

Page 1

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0002

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 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 for 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.
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.
I have not filed nor do I expect to file a lawsuit or claim against any person or company for
a personal injury where I also received sickness benefits as a result of that injury.

RRB Form AA-1cert (xx-xx)

81311 19200 22000 06051 32704

Page 2

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0002

I have filed a lawsuit or claim against the following person or company for a personal
injury where I also received sickness benefits as a result of that injury.
Union Pacific
Omaha, Nebraska
Earnings Information
In 2016, I expect my total nonrailroad earnings will be less than $15,720.
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 are enrolled in the Medicare Medical Insurance Plan (Part B).
Application for Employee Annuity - Certification
RR Claim Number
Name
Social Security Number

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

I certify that the information I have given to the Railroad Retirement Board (RRB) in
relation to 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 a summary of the information I provided. I understand that I
have an obligation to advise the RRB immediately if there are any errors in the summary I
received, and I have made and initialed any corrections on the summary being returned to
the RRB.
I have received and reviewed the booklets RB-1, Age and Service Employee Annuity,
RB-9, Employee and Spouse Annuities - Events that Must be Reported, and Form G-77a,
How Work Affects Your Railroad Retirement Benefits. I understand that I am responsible
for reporting events that would affect my annuity as explained in the booklets and form.
Failure to report any of the events listed below or other events that may affect my annuity,
RRB Form AA-1cert (xx-xx)

81311 19200 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0002

may result in a penalty deduction from my annuity, as well as criminal and/or civil
prosecution.
I agree to immediately notify the RRB, if
 I return to work for a railroad or railroad labor organization or return to work in any
capacity in the railroad industry.
 I receive a lump-sum payment or begin to receive a pension based on earnings that
are not covered by the Social Security Administration or Railroad Retirement Board.
 I file for social security benefits based on any person’s earnings record.
 Benefits I receive directly from the Social Security Administration are adjusted for a
reason other than normal cost-of-living increases.
 I earn over the annual earnings exempt amount.
 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.).
 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.
 I receive anything of value in lieu of salary or wages for any work that I performed.
 I receive a settlement with credit for railroad service as “pay-for-time-lost” for months
after 2/29/2016.
 My address changes.
 My financial organization or the account number at my financial organization
changes.
 I am confined in a jail, prison, penal institution, or correctional facility due to a
conviction for a criminal offense.
 My spouse who is receiving a benefit dies or our marriage ends in divorce or
annulment;
 A qualifying child marries or leaves my custody or residence.

_________________________________
Signature (First Name, Middle Initial, Last Name)

_________________________________
Date (Month/Day/Year)

If this certification is signed by mark (“X”), two witnesses who know the person signing must sign below, giving their
full addresses and daytime telephone numbers.

_______________________________________
Signature of Witness

RRB Form AA-1cert (xx-xx)

_____________________________________
Signature of Witness

81311 19200 22000 06051 32704

Page 4

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0002

_______________________________________
Address (Street, City, State and ZIP Code)

_____________________________________
Address (Street, City, State and ZIP Code)

(_____)_________________________________
Daytime Telephone Number

(_____)_______________________________
Daytime Telephone Number

RRB Form AA-1cert (xx-xx)

81311 19200 22000 06051 32704

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