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UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD
FORM APPROVED
O.M.B. No. 3220-0030
DO NOT WRITE IN THIS SPACE
OFFICIALLY FILED
MONTH
APPLICATION FOR
DETERMINATION OF
CHILD’S DISABILITY
DAY
OFFICE NUMBER
YEAR
APPROVED
APPLICATION NUMBER
DATE CODED
MONTH
DAY
YEAR
CODED BY
Section 1
General Instructions
Before you complete this application, be sure to read Part I of booklet RB-19a, Child’s Disability Benefits, which explains
information you will need to answer many of the questions in this application.
Please read “Important Notices” on page 13 of this application.
Print all answers in ink or use a typewriter. If you need more space than is provided to answer a question, use Section 9 for
this purpose. If you do not know the answer to a question, print “unknown” in the space provided for the answer.
When entering dates, always use numbers. Also, be sure there is one number in each box. For example, you would enter
February 12, 2000, as:
MONTH
DAY
YEAR
0 2 1 2 0 0
Some items in this application will not apply to you so you will not need to answer them. Based on your answer to a
question, you may be told to skip to another item number, or even another section. Follow the instructions that tell you to
“Go to” another item. These are designed to save you time and help you move through the application form quickly, filling
in only necessary information. If no “Go to” instructions are given, answer the next item in order. Do not skip any
items unless directed to do so.
If you are completing this application on behalf of someone else, you must answer each question as it applies to
the applicant.
Section 2
Identifying Information
Check the information entered by Railroad Retirement Board (RRB) for Items 1 through 9 for accuracy.
If the information is correct, go to Section 3.
If the information is not correct, cross out the incorrect information and enter the correct information above it.
If the information is missing, fill it in.
Employee
Identification 1
Applicant
Identification
EMPLOYEE’S NAME
2
EMPLOYEE’S SOCIAL SECURITY NUMBER
3
EMPLOYEE’S RAILROAD RETIREMENT CLAIM NUMBER
4
CHILD’S NAME
5
a STREET ADDRESS
b CITY AND STATE
c ZIP CODE
d COUNTY
6
DAYTIME TELEPHONE NUMBER
7
CHILD’S SOCIAL SECURITY NUMBER
8
CHILD’S DATE OF BIRTH
9
CHILD’S GENDER
o FEMALE
o MALE
Form AA-19a (10-07) Destroy Prior Editions
Section 3
Medical
Condition
When
Condition
Began
When
Condition
Became
Severe
How
Condition
Affects
Work
Current
Work
Status
Information About The Child’s Medical Condition
10
Describe the child’s medical condition. Enter the exact diagnosis if known and any secondary condition.
11
Enter the date this condition began to affect the child.
12
Enter the date this condition began to severely interfere with the child’s
activities.
13
Enter an “X” in the appropriate box:
Has this condition kept the child from working?
14
Describe how this condition has kept the child from working.
15
Enter an “X” in the appropriate box:
Does this condition prevent the child
from working now?
16
Day
Year
Month
Day
Year
R Yes
R No
Go to Item 14
R Yes
R No
Go to Item 17
Go to Item 15
Go to Item 16
Month
Enter the date this condition no longer
prevented work.
Section 4
Month
Day
Information About The Child’s Medical Care
Medical
17
Care or
Examination
Enter an “X” in the appropriate box:
Has the child received any medical care, or been examined
for this condition since the date in Item 12?
Medical
Care
Before 22
Enter information about each doctor or medical facility from whom the child received treatment
or care before age 22.
18
a NAME OF FACILITY
R Yes
R No
Go to Item 18
Go to Section 5
ADDRESS AND ZIP CODE
ATTENDING PHYSICIAN’S NAME
Enter an “X” in the appropriate box:
INPATIENT
R
OUTPATIENT
R
Area Code
PATIENT NUMBER
DATES TREATED
OR TESTED
Form AA-19a (10-07)
DESCRIBE TYPE OF TREATMENT OR TESTING
Page 2
Telephone Number
Year
Medical
Care
Before 22
(Cont.)
18 b
NAME OF FACILITY
ADDRESS AND ZIP CODE
ATTENDING PHYSICIAN’S NAME
Enter an “X” in the appropriate box:
INPATIENT
R
OUTPATIENT
R
Area Code
PATIENT NUMBER
DATES TREATED
OR TESTED
Telephone Number
DESCRIBE TYPE OF TREATMENT OR TESTING
c NAME OF FACILITY
ADDRESS AND ZIP CODE
ATTENDING PHYSICIAN’S NAME
Enter an “X” in the appropriate box:
INPATIENT
R
OUTPATIENT
R
Area Code
PATIENT NUMBER
DATES TREATED
OR TESTED
Telephone Number
DESCRIBE TYPE OF TREATMENT OR TESTING
Note: If the child received more medical care before age 22, use Section 9
to discuss additional treatment or care. Include the dates for each period of care.
Other
Medical
Care
19
Enter information about any other doctor or medical facility from whom the child has received treatment or
care since the date in Item 12.
a NAME OF FACILITY
ADDRESS AND ZIP CODE
ATTENDING PHYSICIAN’S NAME
Enter an “X” in the appropriate box:
INPATIENT
R
OUTPATIENT
R
Area Code
PATIENT NUMBER
DATES TREATED
OR TESTED
Telephone Number
DESCRIBE TYPE OF TREATMENT OR TESTING
Page 3
Form AA-19a (10-07)
Other
Medical
Care
(Cont.)
19 b
NAME OF FACILITY
ADDRESS AND ZIP CODE
ATTENDING PHYSICIAN’S NAME
Enter an “X” in the appropriate box:
INPATIENT
R
OUTPATIENT
R
Telephone Number
Area Code
PATIENT NUMBER
DESCRIBE TYPE OF TREATMENT OR TESTING
DATES TREATED
OR TESTED
Note: If the child received more medical care, use Section 9 to discuss
additional treatment or care. Include the dates for each period of care.
Activity
Restriction
Medication
20
Enter an “X” in the appropriate box:
A medical doctor restricted the child’s daily
activities since the date in Item 12.
R Yes
R No
21
Enter the name of the medical doctor
who imposed the restriction.
22
Enter the date the restriction began.
23
Describe the restriction.
24
Enter the address of the
medical doctor in Item 21,
if it has not previously been
printed in Items 18 or 19.
25
Enter an “X” in the appropriate box:
Medication has been prescribed for the child?
26
Go to Item 21
Go to Item 25
Month
R Yes
R No
Go to Item 26
Go to Section 5
Enter the name or type of medication and the dosage from the prescription label.
Enter information for all medications prescribed for the child.
NAME/TYPE:
Form AA-19a (10-07)
DOSAGE: (grams, number of pills, etc.)
Page 4
FREQUENCY:
Year
Section 5
Daily
Activities
27
28
Information About The Child’s Daily Activities
Enter an “X” in the appropriate box:
Does the child attend a health or
socialization center daily?
Enter the name, address, and
daytime telephone number of
the center.
R Yes
R No
Go to Item 28
Go to Item 29
NAME OF FACILITY
STREET ADDRESS
CITY AND STATE
ZIP CODE
Area Code
29
After each activity listed below, check the one box that best describes the child’s ability to do that activity.
O EASY — The child can easily do the activity.
O HARD — The child can do the activity with difficulty or with help.
O NOT AT ALL — The child cannot do the activity even with help.
ACTIVITY
EASY HARD
NOT
AT ALL
Bathing
R
R
R
R
R
R
R
R
R
R
R
R
R
R
R
Dressing (Tying Shoes,
Combing Hair, Etc.)
R
R
R
Other Bodily Needs
R
R
R
Indoor Chores (Meal
Preparation, Laundry,
Cleaning, Etc.)
R
R
R
Outdoor Chores (Shopping,
Yardwork, Etc.)
R
R
R
R
R
R
R
R
R
Conducting Personal
Business (Talking to and
Dealing with Other People)
R
R
R
Reading English (For
example, newspapers
and magazines)
R
R
R
Writing English (For example,
notes and letters)
R
R
R
Sitting
Standing
Walking
Eating
Driving a Motor Vehicle
Using Public Transportation
30
Telephone Number
EXPLANATION — Explain each “HARD” answer.
Describe the child’s participation in social activities, hobbies, and home or family activities, including chores.
Page 5
Form AA-19a (10-07)
Daily
Activities
(Cont.)
31
What are the child’s activities on a typical day, in terms of physical and mental exertion, and contact
with others?
Section 6
Schooling
and
Training
32
First
School
Attended
33
Information About The Child’s Education And Training
Enter an “X” in the appropriate box:
Has the child ever attended any type of school or
received some type of special training?
Enter the name and address
of the first school the child
attended.
R Yes
R No
Go to Item 33
Go to Section 7
NAME
STREET ADDRESS
CITY AND STATE
ZIP CODE
Second
School
Attended
34
Describe the type of school or training.
35
Enter the dates the child attended school or training.
If the child is still in attendance at this school,
draw a line in the “To” boxes.
36
Enter the highest level the child achieved.
37
Enter the name and address
of the second school the
child attended. If none, enter
“NONE” and go to Item 45.
From
Month
To
Year
Month
Year
Month
Year
NAME
STREET ADDRESS
CITY AND STATE
ZIP CODE
38
Describe the type of school or training.
39
Enter the dates the child attended school or training.
If the child is still in attendance at this school,
draw a line in the “To” boxes.
40
Enter the highest level the child achieved.
Form AA-19a (10-07)
Page 6
From
Month
To
Year
Third
School
Attended
41
Enter the name and address of the third
school the child attended. If none, enter
“NONE” and go to Item 45.
SCHOOL’S NAME
STREET ADDRESS
CITY AND STATE
ZIP CODE
42
Describe the type of school or training.
43
Enter the dates the child attended school or training.
If the child is still in attendance at this school, draw a
line in the “To” boxes.
44
Enter the highest level the child achieved.
From
Month
To
Year
Month
Year
Note: If the child attended more than three schools, complete
Item 45 and use Section 9 to discuss the other schools.
Problems
in School
45
Section 7
Any Work
Most
Recent
Job
46
47
Describe any special problems or difficulties the child had in school.
Information About The Child’s Work Activities
Enter an “X” in the appropriate box:
Has the child ever worked?
R Yes
R No
Go to Item 47
Go to Section 8
Enter the title of the child’s most
recent job.
48 a Enter the employer’s name and address.
b Describe the type of business.
EMPLOYER’S NAME
STREET ADDRESS
CITY AND STATE
c Is this a sheltered employment?
R Yes
R No
49
ZIP CODE
Enter the dates the child worked at this job.
If the child is still working at this job, draw a line
in the “To” boxes.
From
Month
To
Year
Month
50
Enter the number of hours worked each week.
51
Describe the child’s basic duties and responsibilities for the job. Include any difficulties the child had or
has performing the full range of duties.
52
Enter an “X” in the appropriate box:
Did the child’s duties differ from those of other
workers with the same job title?
Page 7
R Yes
R No
Year
Go to Item 53
Go to Item 54
Form AA-19a (10-07)
Most
Recent
Job
(Cont.)
Second
Most
Recent
Job
53
Describe how the child’s duties differed from those of other workers with the same job title.
54
Describe the amount of supervision and assistance the child received.
55
Explain why the child stopped working at this job. If the child is still working, go to Item 56.
56
Enter the title of the child’s second most recent job.
If none, enter “NONE”and go to Item 65.
57 a Enter the employer’s name and address.
b Describe the type of business.
EMPLOYER’S NAME
STREET ADDRESS
CITY AND STATE
c Is this a sheltered employment?
R Yes
R No
ZIP CODE
From
To
58
Enter the dates the child worked at
this job.
59
Enter the number of hours worked each week.
60
Describe the child’s basic duties and responsibilities for the job. Include any difficulties the child had or
has performing the full range of duties.
61
Enter an “X” in the appropriate box:
Did the child’s duties differ from those of other
workers with the same job title?
Month
R Yes
R No
Year
Month
Go to Item 62
Go to Item 63
62
Describe how the child’s duties differed from those of other workers with the same job title.
63
Describe the amount of supervision and assistance the child received.
Form AA-19a (10-07)
Page 8
Year
Second
Most
Recent
Job
(Cont.)
64
Explain why the child stopped working at this job.
Note: If the child had more than two jobs, use Section 9 to discuss the other jobs.
Work for
an
Employer
Last 12
Months
65
66
67
Self68
employment
Last 12
Months
69
70
Work Next
12 Months
71
Enter an “X” in the appropriate box:
Has the child worked for pay for an employer
in the last 12 months?
(Do not include any self-employment.)
R Yes
R No
Go to Item 66
Go to Item 68
Enter the child’s earnings, before any deduction, for each month the child has already worked this year.
Then, starting with the current month, enter the child’s expected gross earnings for that month and each
remaining month this year.
JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
Enter the child’s earnings, before any deduction, for each month last year.
JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
Enter an “X” in the appropriate box:
Has the child been self-employed in the last 12 months?
R Yes
R No
Go to Item 69
Go to Item 71
Enter the child’s earnings, before any deduction, this month and for each month the child worked this year.
Then, starting with the current month, enter the child’s expected earnings for that month and each remaining
month this year.
JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
Enter the child’s earnings, before any deduction, for each month last year.
JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
Enter an “X” in the appropriate box:
Does the child expect to work during the next 12 months?
(Include self-employment, if any.)
Page 9
R Yes
R No
Go to Item 72
Go to Section 8
Form AA-19a (10-07)
Work Next
12 Months
(Cont.)
72
73
74
Enter the name and address of the person or
company for whom the child expects to work.
(If self-employed, enter “Self.”)
Enter the dates the child expects to work.
(For example, “June and July,” “Indefinitely
Starting 12-98,” etc.)
Enter the gross amount the child expects
to earn. (If self-employed, enter the net
amount.)
Section 8
Filing AA-3,
AA-18, or
AA-19
75
Guardianship 76
77
78
General Information
Enter an “X” in the appropriate box:
Are you filing Form AA-3, Form AA-18, or
Form AA-19, at this time?
R Yes
R No
Go to Item 89
Enter an “X” in the appropriate box:
Has the court appointed a legal guardian for the child?
R Yes
R No
Go to Item 77
Enter an “X” in the appropriate box:
Are you the court appointed guardian for the child?
R Yes
R No
Go to Item 79
Enter the name, address, and
daytime telephone number of
the guardian.
Go to Item 76
Go to Item 79
Go to Item 78
NAME
STREET ADDRESS
CITY AND STATE
Telephone Number
Area Code
ZIP CODE
79
Enter an “X” in the appropriate box:
Is the child currently in your care?
80
Enter the name, address, and
daytime telephone number of
the guardian.
R Yes
R No
Go to Item 82
Go to Item 80
NAME
STREET ADDRESS
CITY AND STATE
Telephone Number
Area Code
ZIP CODE
Child’s
Marital
Status
81
Enter the guardian’s relationship
to the child.
82
Enter an “X” in the appropriate box:
Has the child married?
R Yes
R No
R Yes
R No
Enter an “X” in the appropriate box:
Is the child still married?
Criminal
Offense
86
Enter an “X” in the appropriate box:
Was the child’s marriage annulled?
R Yes
R No
87
Enter an “X” in the appropriate box:
Have you filed, or do you expect to file, for monthly
social security disability benefits or SSI for the child?
R Yes
R No
88
Enter the social security claim number and suffix under
which you have filed or will file.
89
Enter an “X” in the appropriate box:
Within the last 12 months, has the child been imprisoned or given a
sentence of confinement due to a conviction for a criminal offense?
Form AA-19a (10-07)
Page 10
Year
Go to Item 85
Day
Year
Go to Item 88
Go to Item 89
Suffix
R Yes
R No
Go to Item 90
Go to Item 98
Month
90 Enter the date of the conviction.
Day
Go to Item 87
Month
85 Enter the date the child’s marriage ended.
Social
Security
Benefits
Go to Item 87
Month
83 Enter the date the child married.
84
Go to Item 83
Day
Year
Criminal
Offense
(Cont.)
91
92 Enter the date of the sentence of confinement.
93 Enter the date that confinement began.
Month
Day
Year
Month
Day
Year
94
Enter an “X” in the appropriate box:
Is the child’s disability related to the confinement?
R Yes
R No
95
Enter an “X” in the appropriate box:
During the confinement, is the child participating in a rehabilitation
program which is expected to result in the ability to engage in gainful
work within a reasonable time after release?
R Yes
R No
96
Enter an “X” in the appropriate box:
R Yes
R No
Has the confinement ended?
Section 9
Go to Item 97
Go to Section 9
Month
97 Enter the date confinement ended.
Remarks
R Yes
R No
Enter an “X” in the appropriate box:
Is the child’s disability related to the commission of the criminal offense?
Day
Year
Remarks
98 This section is to be used for the continuation of 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 space to enter any additional
information that you feel may be important to include.
Page 11
Form AA-19a (10-07)
Section 10
Certification 99
Certification
Enter an “X” in the appropriate box:
A guardian or other representative will sign this
application on behalf of the child applicant.
R Yes
R No
Go to Note and Item 100
Go to Item 99
Note: If answered “Yes,” the guardian or other representative of the
applicant must sign this application. That person must also complete
and return Form AA-5, Application for Substitution of Payee.
100
I know that if I make a false or fraudulent statement in order to receive benefits from the RRB, or if I fail to disclose earnings or report employment of any kind to the RRB, I am committing a crime which is punishable
under Federal law. I have received the booklet, RB-19a, Child’s Disability Benefits. I understand that I am
responsible for reporting any events that would affect my annuity, as explained in that booklet.
I certify that the information I gave to the RRB on this application is true to the best of my knowledge.
I agree to immediately notify the RRB:
O
If the child performs work for any employer, railroad or nonrailroad, or performs any self-employment work.
O
If the child reported estimated earnings and the amount changes;
O
If the child’s condition improves and a doctor advises the child is able to work;
O
If the child dies;
O
If the child marries;
O
If an application is filed for social security benefits for the child based on any person’s earnings records;
O
If the child’s address changes;
O
If I am receiving payments on behalf of the child and the child leaves my care;
O
If the child is confined in a jail, prison, penal institution, or correctional facility due to a conviction for a
criminal offense.
I know that if I am receiving a disability annuity and fail to report work and earnings promptly, I am committing
a crime punishable by Federal law and may result in criminal prosecution and/or penalty deductions in my
annuity payments.
Signature
(First Name, Middle Initial,
Last Name)
Month
Day
Year
Date
101
If this certification is signed by mark (“X”) in Item 100, 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 (include area code)
Area Code
Telephone Number
Area Code
Telephone Number
b Signature of Witness
Address (Number and Street)
City, State and ZIP Code
Daytime Telephone Number (include area code)
Form AA-19a (10-07)
Page 12
Section 11
How To Return Your Application
Before you return your application, check to make sure that:
k
Every question that applies to you has been answered.
k
You have entered “unknown” in any answer space for which you were unable to answer a question.
k
You have signed and dated the application.
k
You have included all the needed proofs listed in the letter you received with this application.
When you received your application, you should also have received a pre-addressed return envelope. If you do not
have this envelope, you can use any envelope as long as it is addressed to the RRB office shown on page 14 of this
application. No matter which envelope you use, you must put the correct postage on the envelope. Be careful to provide enough postage, because your application and the accompanying forms may weigh more than a standard letter.
The U.S. Postal Service will not deliver your application unless it has the correct postage.
Make one final check before you seal the envelope to ensure that the following are enclosed:
k
NEEDED PROOFS
k
THE APPLICATION FORM ITSELF
k
ADDITIONAL FORMS YOU WERE ASKED TO COMPLETE
Note: Make no entries on page 14, which is the receipt for your claim. After the RRB receives your application,
they will complete the blanks on the receipt and send it back to you. When it is returned to you, you will know
that the RRB has received your application and has started the work needed to determine if you are entitled to
benefits. If you do not receive the receipt within two weeks after you filed this application, please contact us so
we can find out what is causing the delay.
Important Notices
PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICES
The information asked for in this form is needed to determine your entitlement to benefits under the Railroad
Retirement Act. The RRB’s authority for requesting this information is Section 7(b)(6) of the Railroad Retirement Act.
We estimate this form takes an average of 45 to 65 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 the completion time, to Chief of Information Resources Management, Railroad
Retirement Board, 844 North Rush Street, Chicago, IL 60611-2092.
COMPUTER MATCHING AND PRIVACY PROTECTION ACT NOTICE
The Computer Matching and Privacy Protection Act of 1988 requires the RRB to advise you that information you
have provided may be used, without your consent, in automated matching programs. These matching programs are
a computer comparison of RRB records with records kept by other Federal, state, or local governmental agencies.
Information from these matching programs can be used to establish or verify a person’s eligibility for federally funded
or administered benefit programs and for repayment of payments or delinquent debts under these programs.
Page 13
Form AA-19a (10-07)
Receipt For Your Claim
Employee’s Name
Railroad Retirement Board Claim Number
Applicant’s Name
Date Claim Received
Your application for a railroad retirement child’s disability annuity 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 or your
representative should report the change. The changes to be reported are listed below. Always give us your claim
number when writing or calling about your claim. If you have any questions about your claim, 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 AM to 3:30 PM, Monday through Friday.
Always Report These Changes To The RRB
G
Work—If the child performs work for any employer,
railroad or nonrailroad, or performs any selfemployment work.
G
Earnings—If the child reported estimated earnings
and the amount changes.
G
Improvement in the Child’s Condition—If the child’s
condition improves and a doctor advises the child is
able to work.
G
Death—If the child dies.
G
Marriage—If the child marries.
G
Social Security—If an application is filed for
social security benefits for the child based on
any person’s earnings record.
G
Address—If the child’s address changes.
G
Child in Your Care—If you receive payment on behalf
of the child, and the child leaves your care.
G
Criminal Offense—If the child is confined in a jail,
prison, penal institution, or correctional facility due to a
conviction for a criminal offense.
How To Report Changes
When a change occurs after the child becomes entitled to a disability annuity, it should be reported at once. You or
your representative can make the reports by telephone, mail, or in person, whichever you prefer.
To report any of the above changes, contact:
L
Telephone Number:
If for some reason you cannot contact that office, you should contact:
L
Form AA-19a (10-07)
U S RAILROAD RETIREMENT BOARD
844 N RUSH ST
CHICAGO IL 60611-2092
Page 14
| File Type | application/pdf |
| File Title | 6-00.PDF |
| Author | OSIKAGL |
| File Modified | 2015-10-15 |
| File Created | 2000-07-31 |