AA-5 (Proposed) Application for Substitution of Payee

United States of America
Railroad Retirement Board

PROPOSED

Form Approved
OMB No. 3220-0052

RRB claim number

Application for
Substitution
of Payee

Employee’s SS number
Employee’s name
Beneficiary’s name

Field office name
and number
Before you complete this application, be sure to read Booklet RB-5, Your Duties As Representative Payee/Representative Payee’s
Record, and the “Important Notices” on page 8 of this application. This application must be completed by the person filing to act as the
representative for the beneficiary.
1

Enter the applicant’s name, address, and daytime telephone number.
(Include Number and Street, P.O. Box or Rural Route, City, State, and ZIP Code.)

Telephone Number

2

Enter the applicant’s Social Security number.
Note: If filing as an administrator of an institution,
enter your Employer Identification Number (EIN).

3

Are you the court appointed legal guardian of the beneficiary?
 Yes - Attach a copy of the court order and go to Item 4
 No - Go to Item 5
Is the court order currently in effect?
 Yes - Go to Item 7
 No - Explain in Item 17 and go to Item 5

4

5

6

Is there a court appointed legal guardian whose court order is currently in effect?
 Yes - Go to Item 6
 No - Go to Item 7
Enter the legal representative’s name, full address, and daytime telephone number.
(Include Number and Street, P.O. Box or Rural Route, City, State, and ZIP Code.)

Telephone Number

7

Does the beneficiary live with you?
 Yes - Go to Item 10
 No - Go to Item 8

8

Enter the name, full address, and daytime telephone number of the person or institution with whom the beneficiary
is living. (Include Number and Street, P.O. Box or Rural Route, City, State, and ZIP Code.)

Telephone Number

Form AA-5 (xx-xx) Destroy Prior Editions

9

What is the relationship between the beneficiary and the person with whom the beneficiary is living?
 Spouse
 Relative (specify relationship) _____________________________________
 Legal Guardian
 Other ________________________________________________________

10 What is your relationship to the beneficiary? (Check all that apply.)
 Spouse
 Relative (specify relationship) ______________________________________

 Legal Guardian - Go to Item 12
 Other ________________________________________________________
11 a Are there any living relatives who are more closely related to the beneficiary than you are?
 Yes - Complete Item 11b
 No - Go to Item 12
11b Enter the name, address, and daytime telephone number of each living relative who is more closely related to
the beneficiary than you. Also show their relationship (parent, child, brother, sister, etc.) to the beneficiary. If
more space is needed, go to Item 17.
(1)

Telephone Number

Relationship

Telephone Number

Relationship

(2)

Note: If you are filing as an administrator of an institution, go directly to Item 14.
12 Are you currently employed?

 Yes - Complete Item 12a
 No - Complete Item 12b
11a Enter your employer’s name and address.

11b Enter your main source of income.
 Self-employed
 Social Security benefits

 Pension
 SSI payments
Form AA-5 (xx-xx) Page 2

 Railroad Retirement benefits
 Welfare benefits
 Other (Describe)
___________________________________________________

13

Have you previously served, or applied and were not selected to serve, as a representative payee for the
beneficiary of a Federal benefit?

 Yes - Complete Items 13a-c
 No - Go to Item 14
11a Enter the name of the beneficiary
11b Enter the Social Security number
of the beneficiary
11c Enter the reason the service
ended.

14

Have you been convicted of a felony?

 Yes - Complete Items 14a-e
 No - Go to Item 15
11a What was the crime?
11b On what date were you convicted?
11c What was your sentence?
11d If imprisoned, when were you
released?
11e If probation was ordered, when
did or will your probation end?
15

Have you been convicted of a misdemeanor under the statutes administered by the Railroad Retirement
Board or Social Security Administration?

 Yes - Complete Items 15a-e
 No - Go to Item 16
11a What was the crime?
11b On what date were you convicted?
11c What was your sentence?
11d If imprisoned, when were you
released?
11e If probation was ordered, when
did or will your probation end?
1611a Why do you believe that you are the best qualified person to receive benefits on behalf of the beneficiary?

11b Please explain how you intend to use the benefits.

Form AA-5 (xx-xx) Page 3

17 Remarks – Use this section to continue 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.

Instructions for Obtaining Form G-478, “Statement Regarding Patient’s Capability to Manage Benefits.”
Depending upon the information furnished in Form AA-5, this additional form may be required.


Form G-478 is required if no guardian or legal representative has been appointed.



Form G-478 is completed either by the beneficiary’s personal physician or by the medical officer of the institution where the beneficiary resides.

Instructions on Information Booklets. You are being provided two or more booklets for your information and use:


The duties and responsibilities of a representative payee are explained in Booklet RB-5, “Your Duties as
Representative Payee/Representative Payee’s Record.” This booklet should be used to maintain a record
of income received and expenditures made for the beneficiary.



The other booklet(s) explains the conditions under which the annuity is not payable, and changes or events
affecting the beneficiary that are to be reported to the RRB.

After you have read the booklets and the Certification on the next page, sign Form AA-5. Form AA-5 (and when
required, Form G-478) should be returned to:

Form AA-5 (xx-xx) Page 4

18 Certification – I understand that civil and criminal penalties may be imposed on 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 affirm that, to the best of my knowledge, the information which I have
given is true, complete, and correct.
I have received, read, and understand Booklet RB-5, Your Duties as Representative Payee/Representative
Payee’s Record. I understand that this booklet is to be used to maintain a record of income received and
expenditures made for the beneficiary. I agree to use all payments made to me on behalf of the beneficiary in the
beneficiary’s interest.
I agree to immediately notify the RRB:

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If the beneficiary is restored to competency by a state court;
If the beneficiary marries, remarries, or divorces;
If I am discharged as the legal guardian;
If a legal guardian is appointed or guardianship changes;
If I am no longer responsible for the beneficiary’s care and welfare;
If I have been convicted of a felony;
If I have been convicted of a misdemeanor under the statutes administered by the RRB or SSA;
If the beneficiary leaves my custody and care;
If my address changes;
If the beneficiary’s address changes;
If the beneficiary performs any work, including self-employment;
If the beneficiary is convicted of a felony;
If the beneficiary begins to receive a public service pension, or there is a change in the amount of the
pension;
If an application for Social Security benefits is filed for the beneficiary on any person’s earnings record;
If a student beneficiary graduates from high school or ceases full-time school attendance;
If the beneficiary is outside the U.S. for more than 30 consecutive days;
If the beneficiary dies.

Signature
(First Name, Middle Initial,
Last Name)

Month

Day

Year

Date
19 If this certification is signed by mark (“X”) in Item 18, two witnesses who know the person signing
must sign below, giving their full addresses and daytime telephone numbers.
a Signature of Witness
Address (Number and Street)
City, State, and ZIP Code
Daytime Telephone Number

Area Code

Telephone Number

Area Code

Telephone Number

b Signature of Witness
Address (Number and Street)
City, State, and ZIP Code
Daytime Telephone Number

Form AA-5 (xx-xx) Page 5

This Space Is For RRB Use Only


The evidence of incompetency of the beneficiary consists of:

 A legal document


 Other - Specify in Remarks below.

The applicant and beneficiary were interviewed in person.

 Yes


 A doctor’s statement

 No - Explain in Remarks below.

If Item 3 is answered “Yes,” I verified that the applicant is the legal representative of the beneficiary and
that the court order is still in effect by:

 examination of a certified copy of the court order


I have verified the applicant’s statement concerning previous representative payee appointment.

 Yes


 personal contact with the court

Explain any discrepancies in Remarks below.

Form RB-5 was explained and furnished to the representative payee on
( Date)



The following informational booklets were also provided to the representative payee:



I select the applicant as representative payee for the beneficiary.

 Yes

 No - Explain in Remarks below

Signature of selecting RRB representative

Signature of reviewing RRB representative

Remarks

Form AA-5 (xx-xx) Page 6

Receipt For Your Claim
Representative Payee Applicant’s Name
Beneficiary’s Name

Beneficiary’s RRB Claim Number

Date Claim Received

Your application for substitution of payee has been received and will be processed as quickly as possible. If you change
your address, or if there is some other change that may affect your claim, you should report the change. The changes
to be reported are listed below. Always give us the beneficiary’s claim number when writing or calling. If you have any
questions, we will be glad to help you. If you need to personally visit one of our field offices, please call for an appointment. You will not be refused service if you do not have an appointment, but our staff can serve you better when
an appointment is made. Most offices are open to the public from 9:00 a.m. to 3:30 p.m., Monday, Tuesday,
Thursday, and Friday, and from 9:00 a.m. to 12:00 p.m. on Wednesday.

Always Report These Changes To The RRB


Death—if the beneficiary dies.





Marital Status—If the beneficiary marries, remarries,
or divorces.

Address—If your address or the beneficiary’s address
changes



Legal Status—If there is any changes in the beneficiary’s competency or legal guardian (appointment, change,
or discharge).



Social Security—If an application is filed for the
beneficiary on any person’s earnings record.



Public Pension—If the beneficiary begins to receive
a pension from an agency of the Federal, state, or
local government, or if the amount changes.



In Your Care—If the beneficiary leaves your care or
custody.



Work—If the beneficiary performs any work, including
self-employment.

School—If a student beneficiary graduates from high
school or ceases full-time school attendance.



Residency—If the beneficiary is outside the U.S. for
more than 30 consecutive days.





Felony and Misdemeanor—If you or the beneficiary
are convicted of a felony offense, or a misdemeanor
under the statutes administered by the RRB or SSA.

How To Report Changes
When a change occurs after you are entitled to receive benefits on behalf of the beneficiary, you should report the
change at once. You can make your reports by telephone, mail, or in person, whichever you prefer. Some telephone
reports may need to be confirmed in writing.



To report any of the above changes, contact:



Telephone Number:



If for some reason you cannot contact that office, you should contact:
U S RAILROAD RETIREMENT BOARD
OFFICE OF PROGRAMS-OPERATIONS
844 N RUSH ST
CHICAGO IL 60611-1275
Form AA-5 (xx-xx) Page 7

Important Notices
Paperwork Reduction Act and Privacy Act Notices
This notice is given under the Paperwork Reduction Act of 1995 and the Privacy Act of 1974. The Privacy Act of
1974 requires that the Railroad Retirement Board (RRB) tell you the following whenever we ask you for informa-

1 ) the law which allows us to ask for the information;
2 ) whether that law requires you to give us the information and what, if anything, might happen if you do not
give the information to us;
3 ) the reason why the information is requested; and
4 ) the persons, organizations and agencies to which we may release the information without your permission.
The RRB’s authority for requesting this information is section 7(b)(6) (45 U.S.C. 231f(b)(6) of the Railroad
Retirement Act. The law does not give the RRB power to force you to give us information. However, if you do
not provide the information which we ask for, we may not be able to pay benefits to you.
The information which we ask you for is used to determine if you are eligible to receive benefits from the RRB.
Some of the information may have an effect on the amount of benefits which we can pay.
Although the information we request is almost never used for any purpose other than the payment of benefits
under the RRA, the RRB does have the authority to release information to the individuals, organizations, and/or
agencies listed below without your approval:

1 ) An attorney, Congressman’s office, labor union or to the Department of State’s embassy or consular offices if they claim to be representing you at your request.
2 ) The U.S. Treasury Department or U.S. Postal Service to issue payments and to investigate lost, forged or
stolen checks.
3 ) The Social Security Administration to resolve discrepancies between appointed payees.
4 ) The Internal Revenue Service or to State and local taxing authorities for figuring your taxes and for use in
audits.
5 ) The Department of Justice for audits and for collecting overpayments owed to the RRB or the Social
Security Administration.
6 ) In certain cases information may be released for law enforcement purposes and for court proceedings.
A complete list of the persons, organizations or agencies to which the information you give us may be released
is available in any office of the RRB.
We estimate this form takes an average of 17 minutes per response to complete, 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 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 N. Rush Street, Chicago, Illinois 60611-1275.

Form AA-5 (xx-xx) Page 8