Information Collection

Application for Survivor Insurance Annuities

IC 33834 under ICR 201812-3220-003 · OMB 3220-0030.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0030 can be found here:

Documents and Forms

Document Name Document Type
Form AA-17b (10-07) Application for Survivor Insurance Annuities Form and Instruction
AA-17b (10-07) Application for Determination of Widow(ers) Disability Form AA-17b (10-07).pdf Form and Instruction
AA-19a (10-07) Application for Determination of Child's Disability Form AA-19a (10-07).pdf Form and Instruction
AA-17cert (09-15)( Application Summary and Certification Form AA-17cert (09-15) (All Possible).pdf Form
AA-17cert (09-15) Application Summary and Certification Form AA-17cert (09-15) (Completed).pdf Form
AA-17sum (01-19) ( Application Summary Form AA-17sum (01-19) (All Possible).pdf Form
AA-17sum (01-19) ( Application Summary Form AA-17sum (01-19) (Completed).pdf Form
AA-17b (Proposed) Application for Determination of Widow(ers) Disability Form AA-17b (Proposed).pdf Form and Instruction
AA-19a (Proposed) Application for Determination of Child's Disability Form AA-19a (Proposed).pdf Form and Instruction
RB-3 (11-08).pdf RB-3 Booklet; Furnishing Evidence to Support Your Claim IC Document
RB-17 (proposed).pdf RB-17 Booklet, Survivor Annuities IC Document
RB-17b (03-19).pdf RB-17b Booklet; Widow(ers) Disability Benefits IC Document
RB-19a (03-19).pdf RB-19A Booklet; Child's Disability Benefits IC Document
Form AA-17rec (01-19).pdf AA-17rec; Receipt for Claim IC Document
Form RL-1S (08-18).pdf RL-1S, Transmittal Letter for Self-administered Retirement Applications IC Document
Form AA-17 (11-18).pdf AA-17, Application for Widow(ers) Annuity IC Document
Form AA-18 (11-18).pdf AA-18, Application for Mother's/Father's and Child's Annuity IC Document
Form AA-19 (11-18).pdf AA-19, Application for Child's Annuity IC Document
Form AA-20 (11-18).pdf AA-20, Application for Parent's annuity IC Document
RB-9s (03-09).pdf RB-9s, Events that Affect a Survivor Annuity IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application for Survivor Insurance Annuities	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 218 20 CFR 216 20 CFR 219 20 CFR 217

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	AA-17b (10-07)	Application for Determination of Widow(ers) Disability	Form AA-17b (10-07).pdf	No		Paper Only
Form and Instruction	AA-19a (10-07)	Application for Determination of Child's Disability	Form AA-19a (10-07).pdf	No		Paper Only
Form	AA-17cert (09-15)(all possible)	Application Summary and Certification	Form AA-17cert (09-15) (All Possible).pdf	Yes	Yes	Printable Only
Form	AA-17cert (09-15)	Application Summary and Certification	Form AA-17cert (09-15) (Completed).pdf	Yes	Yes	Printable Only
Form	AA-17sum (01-19) (All possible)	Application Summary	Form AA-17sum (01-19) (All Possible).pdf	Yes	Yes	Printable Only
Form	AA-17sum (01-19) (Completed)	Application Summary	Form AA-17sum (01-19) (Completed).pdf	Yes	Yes	Printable Only
Form and Instruction	AA-17b (Proposed)	Application for Determination of Widow(ers) Disability	Form AA-17b (Proposed).pdf	No		Paper Only
Form and Instruction	AA-19a (Proposed)	Application for Determination of Child's Disability	Form AA-19a (Proposed).pdf	No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: RRB-22, Railroad Retirement, Survivor, and Pensioner Benefit System	FR Citation: 79 FR 58874

Number of Respondents: 3,485	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 86 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	3,485	0	3,485
Annual IC Time Burden (Hours)	1,337	22	1,315
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
RB-3 Booklet; Furnishing Evidence to Support Your Claim	RB-3 (11-08).pdf	07/16/2009
RB-17 Booklet, Survivor Annuities	RB-17 (proposed).pdf	12/21/2018
RB-17b Booklet; Widow(ers) Disability Benefits	RB-17b (03-19).pdf	03/15/2019
RB-19A Booklet; Child's Disability Benefits	RB-19a (03-19).pdf	03/15/2019
AA-17rec; Receipt for Claim	Form AA-17rec (01-19).pdf	12/21/2018
RL-1S, Transmittal Letter for Self-administered Retirement Applications	Form RL-1S (08-18).pdf	03/18/2019
AA-17, Application for Widow(ers) Annuity	Form AA-17 (11-18).pdf	12/21/2018
AA-18, Application for Mother's/Father's and Child's Annuity	Form AA-18 (11-18).pdf	12/21/2018
AA-19, Application for Child's Annuity	Form AA-19 (11-18).pdf	12/21/2018
AA-20, Application for Parent's annuity	Form AA-20 (11-18).pdf	12/21/2018
RB-9s, Events that Affect a Survivor Annuity	RB-9s (03-09).pdf	03/18/2019

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.