AA-1sum (Proposed) Application Summary

United States of America
Railroad Retirement Board

PROPOSED (ALL POSSIBLE)

Form Approved
OMB No. 3220-0002

APPLICATION SUMMARY FOR (AN EMPLOYEE ANNUITY/
A DISABLED EMPLOYEE ANNUITY/MEDICARE)
RRB Claim Number
Name
Social Security Number
The following information was either supplied by or verified by you in support of your
application for (an Employee Annuity/a Disabled Employee Annuity/Medicare) under the
Railroad Retirement Act. Review the information for accuracy. If there are any errors,
notify the Railroad Retirement Board (RRB) immediately, and no later than 10 days from
the date you receive this summary.
This information is certified by you to be true and correct to the best of your knowledge.
You have been informed and you acknowledge that making a false or fraudulent
statement or withholding information, in order to receive benefits from the RRB, is a crime
under Federal law, which may be punishable by fines, imprisonment or both.
Military Service
1

I was not in active military service.

2

I was in active military service.

Recent Employment
3

I did not work for an employer outside the railroad industry during the last six months
or since leaving the railroad industry.

4

I worked for the following employers outside the railroad industry during the last six
months or since leaving the railroad industry.
(Company Name)
(Company Name)
(Company Name)

5

I worked for the following employers as a seasonal employee:
(Company Name)
(Company Name)
(Company Name)

6

from 99/99/9999 to 99/99/9999
from 99/99/9999 to 99/99/9999
from 99/99/9999 to 99/99/9999

from 99/99/9999 to 99/99/9999
from 99/99/9999 to 99/99/9999
from 99/99/9999 to 99/99/9999

I was self-employed during the last six months.

RRB Form AA-1sum (xx-xx)

81311 19200 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

Railroad Employment
7

You have a current connection with the railroad industry.

8

A current connection with the railroad industry is “deemed” because you:
1 Have at least 25 years of railroad service, and
2 “Involuntarily and without fault” stopped working for the railroad on or after
October 1, 1975 and was never called back to work for the railroad employer,
and
3 Did not decline an offer from a railroad employer to return to a job in the same
“class or craft” as the last railroad job.

9

You do not have a current connection with the railroad industry.

10 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

Name and Address
Daytime Telephone Number
Alternate Telephone Number
Date of Birth
Type of Application Filed

(Employee Annuity/Disabled Employee Annuity/
Medicare)

Application Filing Date
11 I am applying for a benefit based on my age and railroad service.
12 I am applying for a benefit based on being disabled.
13 You have requested that any payment due you be sent to the following bank account:
Bank Name
Routing Number
Account Number
Account Type

RRB Form AA-1sum (xx-xx)

81311 19200 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

14 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.
15 Any payment due you will be sent to the address shown above.
Marriages
16 I have never been married.
17 I am currently married or separated.
18 I was previously married.
Family
19 I have a child or children who are unmarried and under age 18.
20 I have a child or children who are unmarried and age 18 through 19 and attending
elementary or secondary school full-time.
21 I have a child or children who are unmarried and age 18 or older with a continuing
disability that began before age 22 and prevents any type of employment.
22 I do not have unmarried qualifying children.
23 I am expecting a newborn. Expected delivery date MMDDYYYY.
24 I am not expecting a newborn.
Other Government Benefits
25 I am currently receiving a social security benefit.
26 I have filed or plan to file in the next three months for social security benefits on my
own account.
27

I have filed or plan to file in the next three months for social security benefits on the
account of:
Name
Social Security Number

RRB Form AA-1sum (xx-xx)

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

28 I have not filed nor do I plan to file in the next three months for social security
benefits on any account number.
29 I have not filed nor do I plan to file in the next three months for social security
benefits on an additional account number.
30 I am not receiving a social security benefit.
31 In the past month I have filed or plan to file in the next three months for railroad
retirement benefits based on the account of:
Name
Claim Number
32 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.
33 I am currently receiving a railroad retirement annuity on another account number.
34 I am receiving or expect to receive a pension or I received or expect to receive a
lump-sum payment instead of a monthly pension based on my earnings after 1956
from an employer not covered by social security or railroad retirement.
35 I am not receiving nor do I expect to receive a pension or lump-sum payment based
on my earnings after 1956 from an employer not covered by social security or
railroad retirement.
Other Benefits
36 I am receiving a railroad pension from ______________.
37 I received a lump-sum payment from _________________.
38 I expect to receive
________________.

a

railroad

pension

or

lump-sum

payment

from

39 I am not receiving nor do I expect to receive a pension or lump-sum payment from a
current or former railroad employer.
40 I have received or I expect to receive worker’s compensation benefits.
41 I have not received nor do I expect to receive worker’s compensation benefits.

RRB Form AA-1sum (xx-xx)

81311 19200 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

42 I have received or I expect to receive disability benefits under a Federal, state or
local government plan or law.
43 I have not received nor do I expect to receive disability benefits under a Federal,
state or local government plan or law.
Miscellaneous Information
44 The RRB has not been furnished with a court order to enforce my child support or
alimony obligation.
45 The RRB has been furnished with a court order to enforce my child support or
alimony obligation.
46 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.
47 The RRB has 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.
48 I had living with me at least one of my own or my spouse’s children, who was under
age 3.
49 I have not had at least one of my own or my spouse’s children, who was under age
3, living with me.
50 I have not received nor do I expect to receive pay for time lost from my last railroad
employer.
51 I have received pay for time lost from my last railroad employer.
52 I expect to receive pay for time lost from my last railroad employer.
53 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.
54 I have received 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.

RRB Form AA-1sum (xx-xx)

81311 19200 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

55 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.
56 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.
57 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.
Name
Address
Address
58 I expect to file 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.
Name
Address
Address
Earnings Information
59 In (prior year), my total nonrailroad earnings were (actual earnings).
60 In (prior year), my nonrailroad earnings were less than (annual exempt amount).
61 In (prior year), I earned more than (monthly exempt amount) in each month.
62 In (prior year), I earned less than (monthly exempt amount) in the following months:
January February March April May June July August September October
November December
63 In (current year), I expect my total nonrailroad earnings will be (estimated earnings).
64 In (current year), I expect my total nonrailroad earnings will be less than (annual
exempt amount).
65 In (current year), I expect to earn more than (monthly exempt amount) in each
month.
66 In (current year), I expect to earn less than (monthly exempt amount) in the following
months:
RRB Form AA-1sum (xx-xx)

81311 19200 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

January February March April May June July August September October
November December
67 In (next year), I expect my total nonrailroad earnings will be (estimated earnings).
68 In (next year), I expect my total nonrailroad earnings will be less than (annual exempt
amount).
Criminal Offense Information
69 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.
70 Within the past 12 months I have been imprisoned or been given a sentence of
confinement due to a conviction for a criminal offense.
Beginning Dates and Filing Dates
71 You have requested your annuity begin on the earliest date permitted by law, even if
you will receive a reduced annuity.
72 You have requested your annuity begin on the earliest date permitted by law, as long
as it does not result in a reduced annuity.
73 You have selected ____________________ for the beginning date of your annuity.
74 This application will protect your filing date for social security benefits.
75 I do not want this application to protect my filing date for social security benefits.
Medicare
76 You are enrolled in the Medicare Medical Insurance Plan (Part B).
77 You wish to enroll in the Medicare Medical Insurance Plan (Part B).
78 You recently applied for the Medicare Medical Insurance Plan (Part B).
79 You do not wish to enroll in the Medicare Medical Insurance Plan (Part B) at this
time.
80 My annuity will begin before I am age 63 and I am totally disabled for work.
RRB Form AA-1sum (xx-xx)

81311 19200 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

81 You are claiming a special enrollment period based on coverage by an employer
group health plan.
82 You are claiming premium surcharge relief based on coverage by an employer group
health plan.
(Printed if application is for Employee Annuity and employee is FRA or older.)
Your application for an Employee Annuity has been released and will be processed as
quickly as possible. If you do not receive notification about your application by
__________ you should contact the field office shown below.
You 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. It is your
responsibility to report events that would affect your annuity as explained in the booklets.
Failure to report any of the events listed below or other events that may affect your
annuity may result in a penalty deduction from your annuity, as well as criminal and/or civil
prosecution.
(Printed if application is for Employee Annuity and employee is under FRA.)
Your application for an Employee Annuity has been released and will be processed as
quickly as possible. If you do not receive notification about your application by
__________ you should contact the field office shown below.
You 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. It is your responsibility to report
events that would affect your annuity as explained in the booklets and form. Failure to
report any of the events listed below or other events that may affect your annuity may
result in a penalty deduction from your annuity, as well as criminal and/or civil
prosecution.

(Printed if application is for Disabled Employee Annuity.)
Your application for a Disability Annuity has been released and will be processed as
quickly as possible. If you do not receive notification about your application by
__________ you should contact the field office shown below.
You have received and reviewed the booklets RB-1, Age and Service Employee Annuity,
RB-1d, Employee Disability Benefits, and RB-9, Employee and Spouse Annuities - Events
that Must be Reported. It is your responsibility to report events that would affect your
annuity as explained in the booklets. Failure to report any of the events listed below or
other events that may affect your annuity may result in a penalty deduction from your
RRB Form AA-1sum (xx-xx)

81311 19200 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

annuity, as well as criminal and/or civil prosecution.
(Printed if application is for Medicare.)
Your application for Medicare has been released and will be processed as quickly as
possible.
(Printed on all applications.)
If you change your address, or if there is some other change that may affect your
application, you or your representative should report the change at once. If you have
any questions, we will be glad to help you. You can report changes either by
telephone, mail, or in person, whichever you prefer. Railroad Retirement Board offices
are open to the public Monday, Tuesday, Thursday, and Friday from 9:00 AM to 3:30
PM, and Wednesday from 9:00 AM to 12:00 PM.
Always Report These Changes to the RRB
 Railroad Work – If you return to work for a railroad or railroad labor organization or
return to work in any capacity in the railroad industry. (Printed if applicant is employee
or disabled employee.)
 Railroad Work – If you change the date you will cease working for _________. On
your application you said that your last day of employment would be
_______________.
 Social Security – If you file for social security benefits based on any person’s
earnings record.
 Social Security – If benefits you receive directly from the Social Security
Administration are adjusted for a reason other than normal cost-of-living increases.
 Public Pension – If you receive a lump-sum payment or begin to receive a pension
based on earnings not covered by the Social Security Administration or Railroad
Retirement Board.
 Pension – If you receive a lump-sum payment or begin to receive a monthly pension.
 Other Benefits – If you begin to receive worker’s compensation or a public disability
benefit.
 Settlement – If you receive a settlement with credit for railroad service as “pay-fortime-lost” for months after _________________.
 Employment – If you return to work for ___________________.
 Employment – If you change the date of last nonrailroad employment. On your
application you said your last day of employment with ___________ would be
_____________.
 Employment – If you cease working for
.
 Employment – If you perform work, including self-employment, for a family owned,
controlled or managed business, including a business operated, managed or owned
by you, 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.).
RRB Form AA-1sum (xx-xx)

81311 19200 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

 Employment – If you 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.
 Employment – If you receive anything of value in lieu of salary or wages for any work
that you performed.
 Earnings – If you work for any employer or perform any self-employment work.
 Earnings – If your earnings change.
 You told us you expect your total nonrailroad earnings for (current year) will be
$________.
 You told us you expect your total nonrailroad earnings for (current year) will be less
than $________.
 You are earning more than $______.
 You are not earning more than $_____.
 Address – If your address changes, even if your payments are sent to a financial
organization. (Printed on employee and disabled employee applications.)
 Address – If your address changes. (Printed if application type is Medicare only.)
 Bank Account – If your financial organization or the account number at your financial
organization changes.
 Criminal Offense – If you are confined in a jail, prison, penal institution, or
correctional facility due to a conviction for a criminal offense.
 Death or Disability – Your representative should notify the RRB immediately if you
die or become unable to handle your own benefits.
 Spouse – If your spouse who is receiving a benefit dies or your marriage ends in
divorce or annulment.
 Child – If a qualifying child marries or leaves your custody or residence.
How to Report Changes
When a change occurs after you have begun receiving your annuity, you should report the
change at once. You or your representative can make the reports by telephone, mail or in
person, whichever you prefer.

(Printed if application is for an employee or disabled employee annuity and applicant is
under FRA.)
In most cases, we calculate how much to reduce your annuity because of your earnings
based on either the earnings estimate you gave us when you applied for benefits, or on
reports submitted by employers to the Social Security Administration. As a reminder, you
should report your earnings (1) when we ask for a report of your earnings or (2) if any of
the following happens:



You stop working;
You start working and expect to earn more than the annual exempt amount;

RRB Form AA-1sum (xx-xx)

81311 19200 22000 06051 32704

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United States of America
Railroad Retirement Board





Form Approved
OMB No. 3220-0002

Your employment is not covered under the Social Security Act (i.e., FICA taxes
are not deducted from your pay);
You work for a railroad or railroad labor organization; or
You return to work for your last pre-retirement nonrailroad employer.

To report any changes or ask questions, you should contact:
(Field Office Address and Toll-Free Telephone Number)

If for some reason you are unable to contact that office, you should contact:
U.S. Railroad Retirement Board
844 N Rush Street
Chicago, Illinois 60611-1275
http://www.rrb.gov

RRB Form AA-1sum (xx-xx)

81311 19200 22000 06051 32704

Page 11