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pdfPROPOSED
UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD
_________
APPLICATION FOR
DETERMINATION
OF WIDOW(ER)’S
DISABILITY
General Instructions
Section 1
FORM APPROVED
O.M.B. No. 3220-0030
_________
1
Before you complete this application, be sure to read Part XI of booklet RB-17b, Widow(er)’s Disability Benefits, which explains information
you will need to answer many of the questions in this application. Please read “Important Notices” on page 12 of this application.
Please read “Important Notices” on page 11 of this application.
--------------------------------------------------------------------------------, Remarks,
legibly
Print all
answers in ink xxxxxxxxxxxxxxx
or use a typewriter. If you need more space than is provided to answer a question, use Section 9 for this purpose. If
xxxxxxxx
Λ
you do not know the answer to a question, print “unknown”
in the space provided for the answer.
U
When entering dates, always use numbers. Also, be sure there is one number in each box. For example, you would enter December 13,
xxxx as:
1998,
2018
__________
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”
xxx skip any items unless directed to do so.
instructions are given, answer the next item in order. Do not
NOT
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
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
APPLICANT'S
PROVINCE
/
R
a
b ALTERNATE TELEPHONE NUMBER
.xxxxxxxx
Section 3
Medical
Condition
7
Information About Your Medical Condition
Describe the medical condition(s) causing you to file. Enter the exact diagnosis if known and any secondary
condition.
See Attached Item 7
When
Condition
Began
8
How
Condition
Affects
Work
9
the
xxx condition began to adversely
Enter the date this
xxxxxxxx affect
your ability to work.
Month
R Yes
R No
Enter an “X” in the appropriate box:
yo
Λ
XI have worked since the date in Item 8.
10 Enter an “X” in the appropriate box:
caused
Has XXX
Did your condition cause
xxxxx you to change:
Your job duties?
Your hours of work?
Your attendance?
Anything else about your work?
11
12
13
Current
Work
Status
Dates
DATES
Section 4
Go to Item 12
No
If ”Yes” to
any item, go
to Item 11
R
R
R
R
If “No” to
all items, go
to Item 12
xxxxxxx
Why Your Condition Made
Changes Necessary
xxxxxxxxxxxxxxxxxxx
CONDITION
Month
Enter the date you could no longer work because of your
condition.(s)
Day
Year
condition(s) revents
Describe how your condition affects you and keeps you from working.
Λ
14a Enter an “X” in the appropriate box:
My condition prevents me from working now.
See Attac ed new Ite s a and
.
15
Go to Item 10
Yes
R
R
R
R
Year
Explain what the changes in your work circumstances were, the dates they occurred, and why your condition
made these changes necessary.
Changes xxxxxxxxxxxxxxxxx
in Work Circumstances
CHANGES
When
Unable to
Work
Day
Enter the date you became able to work again.
C rrent Ite
is ein deleted
Go to Section
4 Item 14b
XXXXXXX
R Yes
R No
Month
XXXXX
Go to Item
15 Section 4
Day
Year
Information About Your Medical Care
Medical
Care or
Examination
16 Enter an “X” in the appropriate box:
yo
a I haveΛreceived medical care or been examined for my yo r
condition since the date in Item 8.
See Attac ed Ite
Treatment or 17 Enter an “X” in the appropriate box:
yo
Testing
I haveΛbeen treated or tested (inpatient or outpatient) at a
hospital, institution or clinic, including a Department of
Veterans Affairs or other government facility.
Form AA-17b (xx-xx)
Page 2
R Yes
R No
R Yes
R No
Go to Item 18
Go to Item 19
Treatment or 18
Testing
(Continued)
Enter information about each hospital, institution, or clinic where you have received treatment or care
since the date in Item 8.
a
Name of Facility
Address and ZIP Code
Address of Facility (Street Address, City, State/Province,
and ZIP Code)
Attending Physician’s Name
Enter an “X” in the appropriate box:
Outpatient R
Inpatient R
Dates Treated or Tested
b
Telephone Number
Area Code
Patient Number
Describe Type of Treatment or Testing
Name of Facility
Address and ZIP Code
Address of Facility (Street Address, City, State/Province,
and ZIP Code)
Attending Physician’s Name
Enter an “X” in the appropriate box:
Outpatient R
Inpatient R
Dates Treated or Tested
Telephone Number
Area Code
Patient Number
Describe Type of Treatment or Testing
c Name of Facility
Address and ZIP Code
Address of Facility (Street Address, City, State/Province,
and ZIP Code)
Attending Physician’s Name
Enter an “X” in the appropriate box:
Outpatient R
Inpatient R
Area Code
Patient Number
Dates Treated or Tested
Doctor
Treatment
19
Telephone Number
Describe Type of Treatment or Testing
Enter an “X” in the appropriate box:
you
me since
ΛMy personal physician or other doctor treatedΛxxx
the date in Item 8.
as yo r
Page 3
R Yes
R No
Go to Item 20
Go to Item 21
Form AA-17b (xx-xx)
Doctor
Treatment
(Continued)
20 Enter information about each personal physician or other doctor who has treated you.
XX
19
a Name of Physician
-----------------------------Address and ZIP Code
Address of Facility (Street Address, City, State/Province,
and ZIP Code)
Dates Treated or Examined
b
Telephone Number
Area Code
Patient Number
Describe Type of Treatment or Testing
Address
and ZIP Code
------------------------------
Name of Physician
Address of Facility (Street Address, City, State/Province,
and ZIP Code)
Area Code
Patient Number
Dates Treated or Examined
Telephone Number
Describe Type of Treatment or Testing
c We are adding new Item 19c to provide room for a third Physician, if needed. Also, addition
makes Item 19 consistent with Item 18, which provides for three Attending Physicians.
Activity
Restriction
21 Enter an “X” in the appropriate box:
XX
Has a
your
20 A
X medical doctor restrictedΛmy
XX daily
Λ
activities since the date in Item 8.?
XX
22 Enter
the name of the medical doctor
-----------------------------------------------------------------------------------------------------who
imposed the restriction.
R Yes
R No
Go to Item XX
22 21
Go to Item XX
25 24
See proposed text for Item 21 below.
21 Enter the name of the medical doctor who imposed the restriction. Also enter the medical doctor's
address if it has not been previously entered in Items 17 or 19.
Address of Medical Doctor
Name of Medical Doctor
(Street Address, City, State/Province and ZIP Code)
MONTH
XX
23 Enter the date the restriction began.
22
24 Describe
the restriction.
XXXXXXXXXXXXXXXX
XX
Removed Current Item 25. Added the text to proposed Item 23.
Form AA-17b (xx-xx)
Page 4
YEAR
For consistency with changes made to the AA-1d, this page and page 6 and 7 duplicate
the language on pages 6-8 of the AA-1d. Items in red are new and others are reworded.
Activity
Restriction
(Cont)
24 List and describe the condition(s) and how your daily activities were restricted by the condition(s).
xx
Medication
xxx
25a Enter an “X” in the appropriate box:
24 Are you currently taking prescribed medication(s)?
Yes
xxx 25
Go to Item 25b
No
23
Go to Section 5
25x
b Enter from the prescription labels the following information for all medications prescribed for you:
Name or type of medication, dosage, and frequency. (For example, Penicillin, 1.5 gram tablet, 3 times a day.)
Name / Type
Information About Your Education And Training
Yes
Go to Item 27b
No
Go to Item 28
27a Enter an “X” in the appropriate box:
Are you currently attending school (including online)?
26 Enter the highest grade of school you completed.
b Enter the date you began attending.
to Present
c Enter an “X” in the appropriate box:
Indicate what type of school you are attending or
enter the services you receive. Use “Other” to
indicate any other type of school not listed.
Technical
Specialized
Vocational
Services:
Other:
Month
28 Enter the date that you last attended school.
29a Enter an “X” in the appropriate box:
Have you attended technical school, or received
specialized/vocational training or services?
Day
Year
Yes
Skip Item 28 and go to Item 29b.
Go to Item 29b
No
Go to Item 30
b Describe the type of technical school you are attending or have attended, or training or services you are receiving or
have received. If you have completed training, enter the period of time you attended or received the training.
Type
Page 5
Yes
Go to Item 31
No
Go to Section 6
Yes
Yes
32 Enter an “X” in the appropriate box:
Have you used any of this training in your work?
To
Go to Item 33
No
31 Enter an “X” in the appropriate box:
Is the degree, certificate, or license you received currently valid?
30 Enter an “X” in the appropriate box:
Have or will you receive a degree, certificate, or license for any
training you received?
From
Schooling
Frequency
Section 5
Dosage (Grams, Number of Pills, Etc.)
Go to Section 6
No
Form AA-17b (xx-xx)
Information About Your Daily Activities
Section 6
34 Check the one box after each activity listed below that best describes your ability to do that activity.
xx
33 •
•
•
•
•
EASY - I can easily do the activity.
DIFFICULT - I can do the activity with difficulty.
HARD - I can only do the activity with assistance.
NOT AT ALL - I cannot do the activity with assistance.
N.A. - Not applicable
Standing
Walking
Eating
Bathing
Dressing (Tying Shoes,
Combing Hair, etc.)
Other Bodily Needs
Indoor Chores (Meal
Preparation, Laundry,
Cleaning, etc.)
Outdoor Chores
(Shopping, Yardwork, etc.)
Driving a Motor Vehicle
Using Public Transportation
Conducting Personal
Business (Talking to
and Dealing with Other
People)
Reading English (For
example, newspapers and
magazines)
Writing English (For
example, notes and
letters)
Form AA-17b (xx-xx)
Page 6
Sitting
Explain each “DIFFICULT,” “HARD,”
and “NOT AT ALL” answer
N.A.
Not
At All
Easy Difficult Hard
Activity
Activities
xx
35 Describe your daily activities during a normal day (i.e., a typical day from the time you get up until you go to bed).
Yes
No
xxx
36a Enter an “X” in the appropriate box:
35a Do you perform any volunteer work?
(Volunteer work is any work performed without pay.)
xxx 35b
Go to Item 36b
34
Go to Item xx
37 36
b Describe the volunteer work that you perform and enter the number of average hours you participate per week.
Volunteer Work
Yes
No
Yes
xxx 35d
Go to Item 36d
xx 36
Go to Item 37
c Enter an “X” in the appropriate box:
Does your condition(s) restrict your ability to perform
volunteer work?
Go to Item xxx
37b 36b
Average Hours Per Week
Go to Section 7
37a
Enter an “X” in the appropriate box:
xxx
36a Do you participate in social or recreational activities?
For example, clubs, traveling, exercise, indoor/outdoor sports,
hobbies/crafts, etc.
d Describe the changes.
No
b Describe the social or recreational activities that you participate in and enter the number of average hours you participate per week.
c Enter an “X” in the appropriate box:
Does your condition(s) restrict your participation in the
activities listed above?
Yes
No
Average Hours Per Week
xxx 36d
Go to Item 37d
Activity
Activities
(Cont)
Go to Section 7
d Describe the changes.
Page 7
Form AA-17b (xx-xx)
See Attached Item 37 (previously Item 39)
Work for an
Employer
This
Calendar
Year
Last
Calendar
Year
xx
40 Enter an “X” in the appropriate box:
you
38 xx
IH
have worked for pay for an employer in the last
12 months. (Do not include any self-employment.)
xx
41
39
This
Calendar
Year
JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
MAY
JUNE
NOVEMBER
DECEMBER
xx
42 Enter your earnings, before any deduction, for each month last year.
40
MARCH
APRIL
JANUARY
FEBRUARY
Last
Calendar
Year
Work Next
12 Months
AUGUST
SEPTEMBER
OCTOBER
xx Enter an “X” in the appropriate box:
43
41 Have you been self-employed in the last 12 months?
xx
44
42
xx
45
43
Note and
XX 42
Go toΛItem 44
R Yes
R No
Go to Item 46
xx 44
(See
attached
Item 41
Note)
Enter your net earnings for each month you have already worked this year. Then, starting with the current month,
enter your expected earnings for this month and each remaining month this year.
JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
Enter your net earnings, before any deduction, for each month last year.
JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
xx Enter an “X” in the appropriate box:
46
44 Do you expect to work during the next 12 months?
(Include self-employment, if any.)
xx Enter the name and address of the
47
45 person or company for whom you
expect to work. (If self-employed,
enter “Self.”)
xx
48
46
Go to Item 43
xx 41
Enter your earnings, before any deduction, for each month you have already worked this year. Then, starting with
the current month, enter your expected gross earnings for this month and each remaining month this year.
JULY
SelfEmployment
xx 39
Go to Item 41
R Yes
R No
Enter the date(s) you expect
to work. (For example, “June
and July,” “Indefinitely Starting
9-96,” etc.)
xx
49 Enter the gross amount you expect
47 to earn. (If you are self-employed,
enter the net amount.)
Form AA-17b (xx-xx)
Page 7X 8
R Yes
R No
xx 45
Go to Item 47
Go to Section 8
Section 8
General Information
Filing AA-17
or AA-18
xx
50 Enter an “X” in the appropriate box:
Are you
48 XXX
I am filing either Form AA-17 or Form AA-18 at
this time.x?
R Yes
R No
Go to Item xx
56 54
Social
Security
Benefits
xx
51 Enter an “X” in the appropriate box:
do you
you
49 XI have
H
filed, or expect to file, for monthly social
security disability benefits?
R Yes
R No
Go to Item 52
xx 50
R Yes
R No
xx 52
Go to Item 54
R Yes
R No
Go to Note and Item xx
56 54
xx
52
50
Public
Service
Pension
Go to Item xx
51 49
xx 51
Go to Item 53
Enter the social security claim number
under which you have filed or will file.
xx
53 Enter an “X” in the appropriate box:
you
Are you
do you
51 XXX
I am receiving or expect to receive a pension or X
I have received
do you
or expect to receive a lump-sum payment instead of a pension
your
based on XX
my earnings from an agency of the Federal, state, or
?
local government.x (Answer “NO” if your only government pension payments are social security, railroad retirement, veterans
affairs, worker’s compensation, or black lung benefits. Also
answer “NO” if you received a lump-sum payment that was just
your contributions to the pension fund plus interest.)
Are you, or were you
xx
I am / was an employee of the Federal Government.x?
54 XXXXXXX
52
Go to Item xx
56 54
Go to Item 55
xx 53
Note: If answered “Yes,” also complete and return the RRB Form G-208, Public
Service Pension Questionnaire, and verification of your pension.
xx
55
53
Enter an
“X” in the appropriate box:
your
were you
On my
I was employed by a state or local
XX last day of employment, xxxx
government or the military service and social security (FICA)
taxes were being deducted from my public service earnings.x?
XX 54
Go to Item 56
R Yes
R No
Go to Note and Item XX
56 54
Note: If answered “No,” also complete and return the RRB Form G-208, Public
Service Pension Questionnaire, and verification of your pension.
Criminal
Offense
56
xx
54
Enter an “X” in the appropriate box:
were you
Within the past 12 months, XXXXXXXXX
I have been imprisoned or
given a sentence of confinement due to a conviction for a
criminal offense.x?
R Yes
R No
57
xx
55
Enter the date of the conviction.
Month
xx
58
56
Enter an “X” in the appropriate box:
Is your disability related to the commission of the
criminal offense?
xx
59
57
Enter the date of the sentence of confinement.
Month
Day
Year
60
xx
58
Enter the date that confinement began.
Month
Day
Year
xx
61
59
Enter an “X” in the appropriate box:
Is your disability related to your confinement?
xx
62
60
Enter an “X” in the appropriate box:
Has the confinement ended?
R Yes
R No
xx
63
61
Enter the date confinement ended.
Month
Page 8X 9
xx 55
Go to Item 57
Go to Section 9
Day
Year
R Yes
R No
R Yes
R No
Go to Item xx
63 61
Go to Section 9
Day
Year
Form AA-17b (xx-xx)
Section 9
Remarks
Remarks
xx
64 This section is to be used for the continuation of answers to other items. Be sure to include the item
62 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.
Form AA-17b (xx-xx)
Page X10
9
10
Section XX
11
Yes
Go to Item 63b
No
Go to Item 64
Yes
Yes
Go to Note and Item 65
No
Go to Item 65
b Enter the name and address of the attorney or non-family
member who assisted with completing this application.
an attorney or non-family member (RRB staff excluded)?
Certification 63a Did you complete this application with the assistance of
Certification
c Did you pay a fee to the attorney or non-family member
who assisted with completing this application?
64 Enter an “X” in the appropriate box:
Will you have a guardian or other representative sign this
application on your behalf?
No
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.
65 I certify that the information I gave the Railroad Retirement Board (RRB) on this application is true to the best of my
knowledge. I know that if I make a false or fraudulent statement or withhold information in order to receive benefits
from the RRB, I am committing a crime under Federal law which may be punishable by fines, imprisonment, or both. I
have received and reviewed the booklets, RB-17b, Widow(er)'s Disability Benefits. I understand that I am
responsible for reporting events that would affect my annuity as explained in the booklet.
I agree to immediately notify the RRB:
• If I xxxxxx
perform work for any employer, railroad or nonrailroad, or perform any self-employment work;
• If my condition improves;
• If I am confined in a jail, prison, penal institution, or correctional facility due to a conviction for a criminal offense;
• If my address changes;
• If I remarry;
• If I file for social security benefits based on any person's earnings record;
• If I begin to receive a pension from an agency of the Federal, state, or local government or
if my present payments changes.
Signature
(First Name, Middle Initial,
Last Name)
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 that may result in criminal prosecution and/or penalty deductions in my annuity payments.
Day
Year
Month
Date
66 If this certification is signed by mark (“X”) in Item 65, two witnesses who know the person signing must sign below,
giving their full addresses and daytime telephone numbers.
a. Signature of Witness
b. Signature of Witness
Address (Number and Street)
Address (Number and Street)
City, State/Province, and ZIP Code
City, State/Province, and ZIP Code
Daytime Telephone Number (include area code)
Daytime Telephone Number (include area code)
(
)
Page 11
(
)
Form AA-17b (xx-xx)
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
13
have this envelope, you can use any envelope as long as it is addressed to the RRB office shown on page XX
12 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
13
Note: Make no entries on page 12,
XX 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.
45
55
xx to xx
We estimate that this form takes and average of 40
50 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
Information Officer for Policy and Compliance,
Associate
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
form, including suggestions for reducing the completion time, toΛChief of
Information Resources Management,
xxxx
Railroad Retirement Board, 844 North Rush Street, Chicago, IL 60611-2092.
1275
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.
Form AA-17b (xx-xx)
Page 12
Receipt For Your Claim
EMPLOYEE’S NAME
APPLICANT’S NAME
RAILROAD RETIREMENT BOARD CLAIM NUMBER
DATE CLAIM RECEIVED
Your application for railroad retirement disability benefits 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,x on
MondayΛxxxxxxxxxxxx
through Friday.
, Tuesday, Thursday and Friday and from 9:00 AM to 12:00 PM on Wednesday.
Always Report These Changes To The RRB
O
Address — If your address changes.
O
Work — If I xxxxxx
perform work for any employer, railroad or nonrailroad, or perform any self-employment work.
O
Remarriage — If you remarry.
O
Condition — If your condition improves.
O
Social Security — If you file for benefits on any person’s earnings.
O
Criminal Offense — If you are confined in a jail, prison, penal institution, or correctional facility due to a conviction
for a criminal offense.
O
Public Service Pension — If you begin to receive a pension from an agency of the Federal, state, or local
government or if your present payments change.
How To Report Changes
When a change occurs after you are entitled to disability benefits, you should report the change 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:
V
Telephone Number:
If for some reason you cannot contact that office, you should contact:
V
U S RAILROAD RETIREMENT BOARD
844 N RUSH ST
CHICAGO IL 60611-2092
XXXX 1275
Page 13
Form AA-17b (xx-xx)
| File Type | application/pdf |
| File Title | AA-17b 01-00.qxd |
| Author | OSIKAGL |
| File Modified | 2018-12-18 |
| File Created | 2003-03-25 |