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pdfPROPOSED
UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD
FORM APPROVED
O.M.B. No. 3220-0030
APPLICATION FOR
DETERMINATION OF
CHILD’S DISABILITY
Section 1
General Instructions
1
Before you complete this application, be sure to read Part XI 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 14 of
this application.
Please read “Important Notices” on page 13 of this application.
---------------------------------------------------------------------------------------, Remarks,
legibly
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
XXXXXXXX
XXXXXXXXXXXXX
Λ
this purpose. If 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
XXXXXXXXXXX
XX as:
February 12, 2000,
December 13, 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” 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.
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
If the information is not correct, cross
out the incorrect information and enter the correct information.XXXXXXX
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
APPLICANT'S
CHILD’S
XXXXXX NAME
5
a STREET ADDRESS
b CITY AND STATE
/PROVINCE
Λ
c ZIP CODE
COUNTRY
d COUNTY
XXXXXXX
6
7
a DAYTIME TELEPHONE NUMBER
b ALTERNATE TELEPHONE NUMBER
APPLICANT'S
CHILD’S SOCIAL SECURITY NUMBER
xxxxxxx
APPLICANT'S
8 XXXXXX
CHILD’S DATE OF BIRTH
9
APPLICANT'S
CHILD’S GENDER
XXXXXX
o FEMALE
o MALE
Form AA-19a (10-07)
XXXX Destroy Prior Editions
Your
Information About XXXXXXXXX
The Child’s Medical Condition
Section 3
Medical
Condition
10
-----------------------------------------------------------------------------------------------------------Describe
the child’s medical condition. Enter the exact diagnosis if known and any secondary condition.
See Attachment Item 10
When
Condition
Began
When
Condition
Became
Severe
How
Condition
Affects
Work
11
your ability to work.
the
Enter the date xxx
this condition began to affect xxxxxxxx
the child.
12
your
the
xxxxxxxxx
Enter the date this
child’s
xxx condition began to severely interfere with the
activities.
13
14
Current
Work
Status
15
16
Year
Month
Day
Year
R Yes
R No
Go to Item 14
Enter an “X” in the appropriate box:
Does this condition prevent xxxxxxxx
the child you
from working now?
R Yes
R No
Go to Item 17
Go to Item 15
Λ
Go to Item 16
Month
Enter the date this condition no longer
prevented work.
Day
Your
Information About XXXXXXXXXX
The Child’s Medical Care
Medical
17 Enter an “X” in the appropriate box:
Have you
Care or
Has the child received any medical care, or been examined
Λ XXXXXXXXX
Examination
18
Day
Enter an “X” in the appropriate box:
you
the
Has this
child from working?
xxxxxxx
xxx condition kept the
Λ
your condition(s) prevents you
Describe how xxxx
this condition
has kept the child from working.
xxxxxxxxxxxxxxxxxxxxxx
Section 4
Medical
Care
Before 22
Month
R Yes
R No
Go to Item 18
Go to Section 5
forΛxxx
this condition since the date in Item 12?
your
you
xxxxxxxxx
Enter information about each doctor or medical facility from whom the
child received treatment
or care before age 22.
a NAME OF FACILITY
ADDRESSand
ANDZIP
ZIP CODE
Address
Code
Address of Facility (Street Address, City, State/Province,
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
xxxx
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
Code
ADDRESSand
ANDZIP
ZIP CODE
Address of Facility (Street Address, City, State/Province,
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
ZIP CODE
Address and
Code
Address of Facility (Street Address, City, State/Province,
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
you
Note: If the
child received more medical care before age 22, use Section 9
xxxxxxx
to discuss additional treatment or care. Include the dates for each period of care.
Other
Medical
Care
19
you have
xxxxxxxxxx
Enter information about any other doctor or medical facility from whom the
child has received treatment or
Λ
care since the date in Item 12.
a NAME OF FACILITY
ADDRESSand
AND ZIP
ZIP CODE
Address
Code
Address of Facility (Street Address, City, State/Province,
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
xxxx
Form AA-19a (10-07)
Other
Medical
Care
(Cont.)
19 b
NAME OF FACILITY
ADDRESSand
AND ZIP
ZIP CODE
Address
Code
Address of Facility (Street Address, City, State/Province,
and ZIP Code)
ATTENDING PHYSICIAN’S NAME
Enter an “X” in the appropriate box:
INPATIENT
OUTPATIENT
R
R
Area Code
PATIENT NUMBER
Telephone Number
DESCRIBE TYPE OF TREATMENT OR TESTING
DATES TREATED
OR TESTED
c We are adding new Item 19c to provide room for a third Facility/Physician, if needed. Also, addition
makes Item 19 consistent with Item 18, which provides for three Facilities/Physicians.
you
XXXXXXX
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
20 Enter an "X" in teh appropriate box:
your
the child’s daily
Has a A
X medical doctor restricted xxxxxxxx
activities since the date in Item 12.?
?
R Yes
R No
Go to Item 21
XX 24
Go to Item 25
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 18 or 19.
Month
Year
Enter the date the restriction began.
22
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXX
23
Describe the restriction.
See Attachment 21-23
----Enter the address of the
24 -----------------------------------medical
doctor in Item 21,
-----------------------------------------------------------------------if it has not previously been
--------------------------------printed in Items 18 or 19.
Medication
Removed Current Item 24. Added the text to
proposed Item 21 above.
25 Enter an “X” in the appropriate box:
XX
24
Medication
has been prescribed for the child?
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
Are you currently taking prescribed medication(s)?
R Yes
R No
Go to Item XX
26 25
Go to Section 5
Enter the name or type of medication and the dosage from the prescription label.
26 -----------------------------------------------------------------------------------------------------------XX
25 Enter
-------------------------------------------------------------------------------information for all medications prescribed for the child.
NAME/TYPE:
DOSAGE: (grams, number of pills, etc.)
FREQUENCY:
See Attachment 25 for revised language and formatting
xxxx
Form AA-19a (10-07)
Page 4
For consistency with changes made to the AA-1d, this page and Page 6 duplicate the language on pages 7-8 of the
AA-1d. Items in red are new.
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
28 •
•
•
•
•
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-19a (10-07)
xxxx
Page 6x
5
Sitting
Explain each “DIFFICULT,” “HARD,”
and “NOT AT ALL” answer
N.A.
Not
At All
Easy Difficult Hard
Activity
Activities
Activities
(Cont)
xx Describe your daily activities during a normal day (i.e., a typical day from the time you get up until you go to bed).
35
29
Former Item 31 renumbered to Item 29.
New Items xxx
36a Enter an “X” in the appropriate box:
Go to Item xxx
36b 30b
Yes
30a Do you perform any volunteer work?
30-31
xx 31
Go to Item 37
(Volunteer work is any work performed without pay.)
No
(taken
from
b Describe the volunteer work that you perform and enter the number of average hours you participate per week.
AA-1d))
Volunteer Work
Yes
No
Yes
Go to Item 36d
xxx 30d
xx 31
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 37b
xxx 31b
Average Hours Per Week
Go to Section 7
X6
xxx
37a Enter an “X” in the appropriate box:
31a 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.
Yes
No
c Enter an “X” in the appropriate box:
Does your condition(s) restrict your participation in the
activities listed above?
Go to Item xxx
37d 31d
Average Hours Per Week
Activity
Go to Section 7X 6
d Describe the changes.
Page 7
X6
xxxx
Form AA-19a (10-07)
Daily
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
31 What are the child’s activities on a typical day, in terms of physical and mental exertion, and contact
Activities
xxxxxxxxxxxxxxxxxxxxx
with others?
(Cont.)
xxxxx
Moved current Item 31 and renumbered to Item 29.
Your
Section 6
Information About XXXXXXXXX
The Child’s Education And Training
Schooling
32 Enter an “X” in the appropriate box:
(including online)
Have you
and
Has
the child ever attended any type of school or
XXXXXXXX
Λ
Λ
Training
received some type of special training?
First
School
Attended
33
R Yes
R No
Go to Item 33
Go to Section 7
Enter the name and address
NAME
of the first school xxxxxxxx
the child you
attended.
STREET ADDRESS
CITY AND STATE/PROVINCE
ZIP CODE
Second
School
Attended
34
Describe the type of school or training.
35
Enter the datesΛthe
child attended school or training.
xxxxxxx
you are
xxxxxxxxx
If the
child is still in attendance at this school, draw a
line in the “To” boxes.
36
Enter the highest level xxxxxxx
the child achieved.
37
Enter the name and address
NAME
of the second school xxx
the you
child attended. If none, enter
xxxx
STREET ADDRESS
"NONE" and go to Item 45.
you
From
Month
To
Year
Month
Year
Month
Year
you
Λ
CITY AND STATE /PROVINCE
ZIP CODE
38
39
40
Describe the type of school or training.
you
Enter the datesΛthe
child attended school or training.
xxxxxxx
you are
If xxxxxxx
the child is still in attendance at this school,
draw a line in the “To” boxes.
you
Enter the highest level the
child achieved.
xxxxxxx
Form AA-19a (10-07)
xxxx
Λ
Page 6X 7
From
Month
To
Year
Third
School
Attended
41
Enter the name and address of the third
you
schoolΛthe
child attended. If none, enter
xxxxxxx
“NONE” and go to Item 45.
SCHOOL’S NAME
STREET ADDRESS
CITY AND STATE/PROVINCE
ZIP CODE
42
Describe the type of school or training.
43
Enter the datesΛxxxxxxxx
the child attended school or training.
you are
IfΛxxxxxxxx
the child xx
is still in attendance at this school, draw a
line in the “To” boxes.
44
Enter the highest level xxxxxxxx
the child achieved.
you
From
Month
To
Year
Month
Year
you
Λ
you
xxxxxxxx
Note: IfΛthe
child attended more than three schools, complete
Item 45 and use Section 9 to discuss the other schools.
Problems
in School
45
Section 7
accommodations or assistance you received.
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
Describe any special problems
or difficulties the child had in school.
Λ
Your
Information AboutΛThe
Child’s Work Activities
XXXXXXXX
Any Work
46 Enter an “X” in the appropriate box:
Has the child ever worked?
Have youxxxxxxxxxxx
your
Most
child’s most
47 Enter the title of the
xxxxxxxx
Λ
Recent
recent job.
R Yes
R No
Go to Item 47
Go to Section 8
Job
48 a Enter the employer’s name and address.
b Describe the type of business.
EMPLOYER’S NAME
STREET ADDRESS
CITY AND STATE/PROVINCE
c Is this a sheltered employment?
R Yes
R No
you
the child worked at this job.
49 Enter the dates xxxxxxx
Λ
you are
IfΛthe
child is still working at this job, draw a line
xxxxxxxxx
in the “To” boxes.
ZIP CODE
From
Month
To
Year
Month
Year
Enter the number of hours worked each week.
you
your
the child’s basic duties and responsibilities for the job. Include any difficultiesΛxxxxxxx
the child had or
51 DescribeΛxxxxxxxx
have xxx
has performing the full range of duties.
50
52
Enter an “X” in the appropriate box:
your
DidΛxxxxxxxx
the child’s duties differ from those of other
workers with the same job title?
Page x
78
R Yes
R No
Go to Item 53
Go to Item 54
Form AA-19a (10-07)
xxxx
Most
Recent
Job
(Cont.)
Second
Most
Recent
Job
53
your
Describe how the
child’s duties differed from those of other workers with the same job title.
xxxxxxxx
54
you
Describe the amount of supervision and assistance xxxxxxx
the child received.
55
you
you are
Explain why xxxxxxx
the child stopped working at this job. If xxxxxxxxx
the child is still working, go to Item 56.
56
your
Enter the title of xxxxxxxx
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 /PROVINCE
c Is this a sheltered employment?
R Yes
R No
you
58 Enter the dates xxxxxxxx
the child worked at
this job.
ZIP CODE
From
Month
To
Year
Month
59
Enter the number of hours worked each week.
you
your
child’s basic duties and responsibilities for the job. Include any difficulties the
child had or
60 Describe the
xxxxxxxx
xxxxxxx
has performing the full range of duties.
have xxx
62
Enter an “X” in the appropriate box:
Go to Item 62
R Yes
your
Did xxxxxxxx
the child’s duties differ from those of other
Go to Item 63
R No
workers with the same job title?
your
Describe how xxxxxxxx
the child’s duties differed from those of other workers with the same job title.
63
you
Describe the amount of supervision and assistance xxxxxxx
the child received.
61
Form AA-19a (10-07)
xxxx
Page x
89
Year
Second
Most
Recent
Job
(Cont.)
64
you
Explain why xxxxxxx
the child stopped working at this job.
you
xxxxxxx
Note: If the
child had more than two jobs, use Section 9 to discuss the other jobs.
Work for
65 Enter an “X” in the appropriate box:
an
Have you xxxxxxxxxxxx
Has the child worked for pay for an employer
Employer
in the last 12 months?
Last
12
xxxxx
(Do not include any self-employment.)
Months
xxxxx
This
Calendar
Year
66
R Yes
R No
Go to Item 66
Go to Item 68
your
you have
xxxxxxxxxx
Enter xxxxxxxx
the child’s earnings, before any deduction, for each month the
child has already worked this year.
your
Then, starting with the current month, enter XXXXXXX
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
New sidehead below
your
xxxxxxxx
child’s earnings, before any deduction, for each month last year.
67 Enter the
Last
Calendar
Year
JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
This
Calendar
Year
Last
Calendar
Year
69
70
Note and
Go toΛItem 69
Go to Item 71
(See
Attached
Item 68
Note)
your
you
Enter XXXXXXX
the child’s earnings, before any deduction, this month and for each monthΛxxxxxxxx
the child worked this year.
Λ
your
Then, starting with the current month, enter the
child’s expected earnings for that month and each remaining
XXXXXXX
Λ
month this year.
Self68 Enter an “X” in the appropriate box:
employment
the child been self-employed in the last 12 months?
XXXXXXXXXX
Λ Has
Last 12
xxxxx
Have you
Months
xxxxx
R Yes
R No
JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
your
Enter XXXXXXX
the child’s earnings, before any deduction, for each month last year.
Λ
JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
See Attached for new Item 71 taken from AA-1d
71 Enter an “X” in the appropriate box:
XX
you
72 Does
xxxxxxxxxxxx
the child expect to work during the next 12 months?
D(Include self-employment, if any.)
Work Next
12 Months
Page X
9 10
R Yes
R No
Go to Item XX
72 73
Go to Section 8
xxxx
Form AA-19a (10-07)
Work Next
12 Months
(Cont.)
address of the person or
72 Enter the name and
XX
you
the child expects
x to work.
73 company for whom XXXXXX
(If self-employed,
youenter “Self.”)
XX
XXXXXX
73 Enter the dates the
child expects
x to work.
74 (For example, “June and July,” “Indefinitely
12-18
xxxxx etc.)
Starting 12-98,"
you
child expectsx
74 Enter the gross amount the
XX
xxxxxxxxx
75 to earn. (If self-employed, enter the net
amount.)
Section 8
Filing AA-3,
AA-18, or
AA-19
XX
75 Enter an “X” in the appropriate box:
76 Are you filing Form AA-3, Form AA-18, or
Form AA-19, at this time?
Guardianship XX
76
77
Deleted
Items
77, 79
and 80
as form
is filled
out by
child or
rep.
General Information
Enter an “X” in the appropriate box:
you
Has the court appointed a legal guardian for XXXXXX
the child?
R Yes
R No
XX 87
Go to Item 89
R Yes
R No
Go to Item xx
77 78
Go to Item 76
XX 77
xx 80
Go to Item 79
77 Enter an “X” in the appropriate box:
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
R Yes
Go to Item 79
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
Are you the court appointed guardian for the child?
Go to Item 78
R No
xxxxxxxxxxxxxxxxxxxxxxxxxx
NAME
78 Enter the name, address, and
daytime telephone number of
STREET ADDRESS
theΛguardian.
court-appointed
CITY AND STATE /PROVINCE
Telephone Number
Area Code
ZIP CODE
79 Enter an “X” in the appropriate box:
R Yes
Go to Item 82
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Is the child currently in your care?
Go to Item 80
R No
NAME
80
Enter the name, address, and
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
daytime telephone number of
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
STREET ADDRESS
xxxxxxxxxxxxxxxxxxxxxxxxxxxx
the guardian.
CITY
AND STATE
xxxxxxxxxxxx
xxxxxxx
ZIP
CODE
Child’s
Marital
Status
81 Enter the guardian’s relationship
XX
79 toyou
the child.
xxxxxxx
Λ
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
Telephone Number
Area Code
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
R Yes
R No
82 Enter an “X” in the appropriate box:
XX
Are you now, or were you previously,
80 Has
the child married?
XXXXXXXX
Λ
you were
XX
83 Enter the date the
xxxxxxx
child married.
Λ
81
xx 85
Go to Item 87
Month
XX
84 Enter an “X” in the appropriate box:
you
82 Are
Is the child still married?
Λ XXXXXXX
your
XX
85 Enter the date XXXXXXX
the child’s marriage ended.
Λ
83
R Yes
R No
86 Enter an “X” in the appropriate box:
XX
your
84 Was XXXXXXX
the child’s marriage annulled?
R Yes
R No
87
XX
85
R Yes
R No
Enter an “X” in the appropriate box:
Have you filed, or do you expect to file, for monthly
social security disability benefits or SSI XXXXXXXX
for the child?
Day
Year
Go to Item XX
87 85
Go to Item XX
85 83
Month
Λ
Social
Security
Benefits
XX 81
Go to Item 83
Day
Year
Go to Item XX
88 86
Go to Item XX
89 87
XX
88 Enter the social security claim number and suffix under
86 which you have filed or will file.
Criminal
Offense
89
XX
87
Enter an “X” in the appropriate box: have you
Within the last 12 months, xxxxxxxxxx
has the childΛbeen imprisoned or given a
sentence of confinement due to a conviction for a criminal offense?
R Yes
R No
Go to Item XX
90 88
Go to Item XX
98 96
Month
XX
90 Enter the date of the conviction.
88
Form AA-19a (10-07)
xxxx
Suffix
Page 10
xx 11
Day
Year
Criminal
Offense
(Cont.)
XX
91
89
R Yes
R No
Enter an “X” in the appropriate box:
your
IsΛxxxxxxxx
the child’s disability related to the commission of the criminal offense?
XX
92 Enter the date of the sentence of confinement.
90
Month
Day
Year
XX
93 Enter the date that confinement began.
91
Month
Day
Year
XX
94 Enter an “X” in the appropriate box:
92 Isyour
xxxxxxxx
the child’s disability related to the confinement?
R Yes
R No
Λ
XX
95
93
Enter an “X” in the appropriate box:
are you
During the confinement, is
the child participating in a rehabilitation
Λxxxxxxxxx
program which is expected to result in the ability to engage in gainful
work within a reasonable time after release?
96 Enter an “X” in the appropriate box:
XX
94 Has the confinement ended?
R Yes
R No
Remarks
Go to Item XX
97 95
Go to Section 9
Month
XX
97 Enter the date confinement ended.
95
Section 9
R Yes
R No
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
XX
96 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
xx 12
xxxx
Form AA-19a (10-07)
Section 10
Section
10
Yes
Yes
No
Go to Item 97b
Go to Item 98
98 Enter an “X” in the appropriate box:
Will you have a guardian or other representative sign this
application on your behalf?
Yes
Go to Note and Item 99
c Did you pay a fee to the attorney or non-family member
who assisted with completing this application?
Go to Item 99
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 97a Did you complete this application with the assistance of
Certification
No
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.
99 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 booklet, RB-19a, Child's Disability Benefits. I understand that I am responsible for
reporting events that would affect my annuity as explained in that booklet.
I agree to immediately notify the RRB:
• If I 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.x;
• If I marry.x;
• If an application is filed for social security benefits for me based on any person's earnings records;
If my reported estimated earnings amount 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
99
64 If this certification is signed by mark (“X”) in Item xx
63, two witnesses who know the person signing must sign below,
XX
100 giving their full addresses and daytime telephoneΛ 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 13
)
Form AA-19a (xxxx
05-17)
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
15
have this envelope, you can use any envelope as long as it is addressed to the RRB office shown on page 14
xx 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
15
Note: Make no entries on page xx
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, includAssociate
Officer for Policy and Compliance
ing suggestions for reducing the completion time, to ΛChief of
Management, Railroad
xxxxxxxxxxxxxxxxxxxxxxx
xx Information ΛResources
xxxx .
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-19a (10-07)
xxxx
Page 13
XX 14
Receipt For Your Claim
Employee’s Name
Applicant’s Name
Railroad Retirement Board Claim Number
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,Λxxxxxxxxxxxx
through Friday.
Tuesdays, Thursday and Friday, and
from 9:00 AM to 12:00 PM on
Always Report These Changes To The RRB
Wednesday.
you
G
G
Work—If xxxxxxxxxx
the child performs
Marriage—If xxxxxxxxxxxxxxxxxxxx
the child marries. you marry.
xxxxxxxx work for any employer,
railroad or nonrailroad, or performs
x any selfG
Social Security—If an application is filed for
employment work.
you
social security benefits forΛxxxxxxxxxx
the child based on
you
G
Earnings—If xxxxxxxxxx
the child reported estimated earnings
any person’s earnings record.
your
and the amount changes.
G
Address—If xxxxxxxxxxxx
the child’s address changes.
your
your
G
xxxxxxxxx
Improvement in xxxxxxxxxxxxx
the Child’s Condition—If
the
child’s
you are
G
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
Child in Your Care—If you receive payment on behalf
condition improves and a doctor advisesΛxxxxxxxxx
the child is
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
of
the child, and the child leaves your care.
able to work.
you are
G
Criminal Offense—If xxxxxxxxxxxx
the child is confined in a jail,
G
xxxxxx
Death—If
the child dies.
xxxxxxxxxxxxxxxxxxxxxxxxxxx
prison, penal institution, or correctional facility due to a
conviction for a criminal offense.
How To Report Changes
you
x entitled to a disability annuity, it should be reported at once. You or
When a change occurs after xxxxxxx
the child becomes
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
U S RAILROAD RETIREMENT BOARD
844 N RUSH ST
XXXX 1275
CHICAGO IL 60611-2092
xx 15
Page 14
xxxx
Form AA-19a (10-07)
ATTACHMENT
Attachment Item 10
Attachment 21-23
Attachment Item 25
Attachment to Item 68
Attachment New Item 71
| File Type | application/pdf |
| File Title | 6-00.PDF |
| Author | OSIKAGL |
| File Modified | 2018-12-21 |
| File Created | 2000-07-31 |