AA-21CERT Complete Application Summary and Certification

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0031

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

John Public
A 123-45-6789

The following information was either supplied by or verified by you in support of your application for Lump
Sum Death Payment 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

123-45-6789
10-17-1971
04-06-2018

Military Service
The employee was not in active military service after September 7, 1939.
Recent Employment
The employee has not worked in the last three years.
The employee’s net earnings from self-employment were less than $400 in each of the last three years.
Railroad Employment
The employee had a current connection with the railroad industry.
Employee’s Family
The employee was not survived by a widow(er) who is eligible for monthly benefits.
The employee was not survived by a surviving divorced spouse who is eligible for monthly benefits.
The employee was not survived by children or grandchildren who are eligible for monthly benefits.
The employee was not survived by a parent who is eligible for monthly benefits.
Applicant Information
Name and Address

Jane Public

Social Security Number
Daytime Telephone Number

987-65-4321
555-151-8121

Type of Application Filed

Lump Sum Death Payment

You applied for this benefit based on being responsible for the payment of the employee’s burial
expenses.
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

You have requested that any payment due you be sent to the following bank account:
Bank Name
Citibank Financial Services
Routing Number
00020050358
Account Number
25987
Account Type
Checking
Burial Expense Information
Total funeral home expenses:

$9,000.00

Amount paid with your own money:

$4,000.00

Amount paid with the employee’s money:

$1,000.00

Amount remaining unpaid:

$4,000.00

Reimbursement
You have not and will not receive money or property to reimburse you for the burial expenses you paid.

Application for Lump Sum Death Payment - Certification

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

A 123-45-6789
John Public
123-45-6789

Applicant’s Name
Applicant’s Social Security Number

Jane Public
987-65-4321

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.
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.
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.
I have received and reviewed the booklet RB-21 LUMP-SUM DEATH PAYMENT, RESIDUAL LUMP-SUM,
AND ANNUITIES UNPAID AT DEATH]

_________________________________
Signature (First Name, Middle Initial, Last Name)
RRB Form AA-21cert (02-00)

___________________
Date (Month/Day/Year)

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

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

_______________________________
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 3