AA-21CERT (All Pos Application Summary and Certification

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0031

CURRENT (ALL POSSIBLE)
APPLICATION SUMMARY and CERTIFICATION
Employee’s Name
RR Claim No.

The following information was either supplied by or verified by you in support of your application for
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.
Employee Information
Social Security Number
Date of Birth
Date of Death
Military Service
1. The employee was not in active military service after September 7, 1939.
2. The employee had military service after September 7, 1939.
Recent Employment
3. The employee has not worked in the last three years.
4. The employee worked for the following companies in the last two years:
(Company Name)
from 99/99/9999 to 99/99/9999
(Company Name)
from 99/99/9999 to 99/99/9999
(Company Name)
from 99/99/9999 to 99/99/9999

5. The employee did not have self-employment earnings in any of the last three years.
6. The employee’s net earnings from self-employment were less than $400 in each of the last three
years.
7. The employee’s net earnings from self-employment were $400 or more in one of the last three years.
Railroad Employment
8. The employee had a current connection with the railroad industry.
9. A current connection with the railroad industry is “deemed” because the employee:
1
2
3

Was alive on October 1, 1981 and had at least 25 years of railroad service, and
"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
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.

RRB Form AA-21cert (02-00)

32948 64791 21999 06051 32704
EE SSN; Appl Typ; current date and time

Page 1

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0031

10. The employee does not have a current connection with the railroad industry.
Employee’s Family
(Application LSDP or RLS to Widow(er))
11. You are not eligible for monthly benefits.
12. You are eligible for monthly benefits.
13. The employee was not survived by a surviving divorced spouse who is eligible for monthly benefits.
14. The employee was survived by a surviving divorced spouse who is eligible for monthly benefits.
15. The employee was survived by a surviving divorced spouse who is not eligible for monthly benefits.
16. The employee was not survived by children or grandchildren who are eligible for monthly benefits.
17. The employee was survived by children or grandchildren who are eligible for monthly benefits.
18. The employee was not survived by a parent who is eligible for monthly benefits.
19. The employee was survived by a parent who is eligible for monthly benefits.
(LSDP PB/E or RLS des bene)
20. The employee was not survived by a widow(er) who is eligible for monthly benefits.
21. The employee was survived by a widow(er) who is not eligible for monthly benefits.
22. The employee was survived by a widow(er) who is eligible for monthly benefits.
23. The employee was not survived by a surviving divorced spouse who is eligible for monthly benefits.
24. The employee was survived by a surviving divorced spouse who is eligible for monthly benefits.
25. The employee was survived by a surviving divorced spouse who is not eligible for monthly benefits.
26. The employee was not survived by children or grandchildren who are eligible for monthly benefits.
27. The employee was survived by children or grandchildren who are eligible for monthly benefits.
28. The employee was not survived by a parent who is eligible for monthly benefits.
29. The employee was survived by a parent who is eligible for monthly benefits.
(AA to P B/E)
30. The employee was not survived by a widow(er).
(AA, TR, SALSA, RLS to Rel)
31. The employee was not survived by a widow(er).
32. The employee was survived by a widow(er)
RRB Form AA-21cert (02-00)

32948 64791 21999 06051 32704
EE SSN; Appl Typ; current date and time

Page 2

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0031

(REL Child)
33. The employee was survived by other children.
34. The employee was not survived by other children.
(REL Grandchild)
35. The employee was not survived by children.
36. The employee was survived by children.
37. The employee was not survived by other grandchildren.
38. The employee was survived by other grandchildren.
(REL Parent)
39. The employee was not survived by children.
40. The employee was survived by children.
41. The employee was not survived by grandchildren.
42. The employee was survived by grandchildren.
(REL Brother & Sister)
43. The employee was not survived by children
44. The employee was survived by children.
45. The employee was not survived by grandchildren.
46. The employee was survived by grandchildren.
47. The employee was not survived by parents.
48. The employee was survived by parents.
49. The employee was not survived by other brothers and sisters.
50. The employee was survived by other brothers and sisters.
Applicant Information
Name and Address
Social Security Number
Daytime Telephone Number
Type of Application Filed

RRB Form AA-21cert (02-00)

Lump Sum Death Payment
Annuity Unpaid at Death
Railroad Tax Refund
Residual Lump Sum Death Payment
32948 64791 21999 06051 32704
EE SSN; Appl Typ; current date and time

Page 3

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0031

51. You applied for this benefit based on being the employee’s “living-with” spouse at the time of death.
52. You applied for this benefit based on being responsible for the payment of the employee’s burial
expenses.
53. You applied for this benefit based on being the funeral home responsible for the final disposition of the
employee’s remains.
54. You applied for this benefit based on your relationship to the employee.
55. You have requested that any payment due you be sent to the following bank account:
Bank Name
Routing Number
Account Number
Account Type
56. You have requested that any payment due you be sent to the address shown above.
57. You have requested that any payment due you be sent to the following bank account:
Bank Name
Routing Number
Account Number
Account Type
58. You have requested that any payment due you be sent to the address shown above.
59. You have requested that any payment due the employee’s estate be sent to the following bank account:
Bank Name
Routing Number
Account Number
Account Type
60. You have requested that any payment due the employee’s estate be sent to the following address.

Burial Expense Information
61. Total funeral home expenses:

$99,999.99

62. Amount paid with your own money:

$99,999.99

63. Amount paid with the employee’s money:

$99,999.99

64. Amount paid with someone else’s money:

$99,999.99

65. Amount remaining unpaid:

$99,999.99

66. Total cost of the grave opening and closing:

$99,999.99

67. Amount paid with your own money:

$99,999.99

68. Amount paid with the employee’s money:

$99,999.99

RRB Form AA-21cert (02-00)

32948 64791 21999 06051 32704
EE SSN; Appl Typ; current date and time

Page 4

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0031

69. Amount paid with someone else’s money:

$99,999.99

70. Total cost of the burial plot:

$99,999.99

71. Amount paid with your own money:

$99,999.99

72. Amount paid with the employee’s money:

$99,999.99

73. Amount paid with someone else’s money:

$99,999.99

74. Total cost of other burial expenses:

$99,999.99

75. Amount paid with your own money:

$99,999.99

76. Amount paid with the employee’s money:

$99,999.99

77. Amount paid with someone else’s money:

$99,999.99

Assumption of Responsibility
78. You have assumed responsibility for the payment of the unpaid funeral home expenses.
Authorization of Payment
79. You have authorized payment of the lump-sum death payment to
Reimbursement
80. You have not and will not receive money or property to reimburse you for the burial expenses you
paid.
81. You have received or expect to receive $99,999.99 [Insert total amount of 2638-BE-REIMB-AMT] to
pay you back for the burial expenses you paid.
Estate
82. The court appointed administrator or executor of the employee’s estate is:
xxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxx
83. The trustee of the employee’s estate is:
xxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxx
84. The representative of the employee’s estate is:
xxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxx
85. A representative for the employee’s estate has not been appointed.

RRB Form AA-21cert (02-00)

32948 64791 21999 06051 32704
EE SSN; Appl Typ; current date and time

Page 5

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0031

Application for Lump Sum Death Payment
Annuity Unpaid at Death
Railroad Tax Refund
SMIB Refund
Residual Lump Sum Death Payment - Certification

Employee’s RR Claim Number
Employee’s Name
Employee’s Social Security Number
Applicant’s Name
Applicant’s Social Security Number

86. 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 in
order to receive benefits from the RRB, I am committing a crime which is punishable under Federal law.
87. 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 have
made and initialed any corrections on the Summary being returned to the RRB.
if the application type 2600-APPL-TYPE-CD = 11.
88. I agree not to request or accept reimbursement from another party for that part of the burial expenses for
which I am reimbursed by the lump-sum death payment.
if the application type is 2600-APPL-TYPE-CD=12.
89. I will either return the payment or refund the excess to the Railroad Retirement Board (RRB) if payment is
made to me by the RRB and the amount is greater than the unpaid expenses at the time I receive the
payment.
90. I have received and reviewed the booklet RB-21 LUMP-SUM DEATH PAYMENT, RESIDUAL LUMPSUM, AND ANNUITIES UNPAID AT DEATH]

_______________________________________
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 number.
___________________________________
Signature of Witness

___________________________________
Signature of Witness

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

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

(_____)_____________________________
Daytime Telephone Number

(_____)_____________________________
Daytime Telephone Number

RRB Form AA-21cert (02-00)

32948 64791 21999 06051 32704
EE SSN; Appl Typ; current date and time

Page 6