AA-3sum (completed Application Summary

CURRENT (COMPLETED)

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0042

APPLICATION SUMMARY FOR A SPOUSE ANNUITY
John Public
A 123-45-6789
123-45-6789
01/02/1940

Employee’s Name
RR Claim No.
Social Security Number
Date of Birth

The following information was either supplied by or verified by you in support of your application for a
Spouse Annuity under the Railroad Retirement Act. Review the information for accuracy. If there
are any errors, notify the Railroad Retirement Board (RRB) immediately, and no later than 10 days
from the date you receive this summary.
This information is certified by you to be true and correct to the best of your knowledge. You have
been informed and you acknowledge that making a false or fraudulent statement or withholding
information, in order to receive benefits from the RRB, is a crime under Federal law which may be
punishable by fines, imprisonment or both.
Applicant Information

Daytime Telephone Number

Jane Public
844 N. Rush Street
Chicago, IL 60611
555-555-1212

Social Security Number

111-22-3333

Date of Birth

02/20/1942

Type of Application Filed

Spouse Annuity

Application Filing Date

07/25/2011

Name and Address

You have requested that any payment due you be sent using the Direct Express® Debit
MasterCard®. Payments will be sent to the address shown above until the card is issued.
Applicant’s Marriages
You are currently married to or separated from the employee.
You were not married before your marriage to the employee.

RRB Form AA-3sum (11-14)

88552 0215 22000 06051 32704

Page 1

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0042

Criminal Offense Information
Within the past 12 months you have not been imprisoned or given a sentence of confinement due to
a conviction for a criminal offense.
Other Government Benefits
You have not filed nor do you plan to file in the next three months for Social Security benefits on any
account number.
You are not receiving a social security benefit.
In the past month you have not filed nor do you plan to file in the next three months for Railroad
Retirement benefits on any other account number.
You are not receiving a railroad retirement annuity.
You are not receiving nor do you expect to receive a pension or lump-sum payment based on your
earnings from a Federal, state or local government agency.
Earnings Information
In 2013, you expect your total earnings will be less than $14,640.
Railroad Work and NonRailroad Work
You have not worked for a railroad, railroad labor organization or other employer in the railroad
industry.
You worked for the following employers outside the railroad industry in the six months before you
expect your annuity to begin.
Jive Records

from 05/20/1997 to 08/01/2011

Beginning Dates and Filing Dates
You have requested your annuity begin on the earliest date permitted by law, even if you will receive
a reduced annuity.
You do not want this application to protect your filing date for Social Security benefits.
Your application for a Spouse Annuity has been released and will be processed as quickly as
possible. If you do not receive notification about your application by December 2, 2012 you should
contact the field office shown below.
You have received and reviewed the booklets RB-30, Spouse/Divorced Spouse Annuity, and RB-9,
Employee and Spouse Annuities - Events that Must be Reported, and Form G-77a, How Work
Affects Your Railroad Retirement Benefits. It is your responsibility to report events that would affect
RRB Form AA-3sum (11-14)

88552 0215 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0042

your annuity as explained in the booklets and form. Failure to report any of the events listed below
or other events that may affect your annuity may result in a penalty deduction from your annuity, as
well as criminal and/or civil prosecution.
If you change your address, or if there is some other change that may affect your application, you or
your representative should report the change at once. If you have any questions, we will be glad to
help you. You can report changes either by telephone, mail, or in person, whichever you prefer.
Most Railroad Retirement Board offices are open to the public from 9:00 AM to 3:30 PM, Monday
through Friday.
Always Report These Changes to the RRB
 Marriage – If your marriage to the employee ends by death or divorce.
 Social Security – If you file for social security benefits based on any person’s earnings record.
 Public Pension – If you receive a lump-sum payment or begin to receive a monthly pension
based on your earnings at an agency of the Federal, state or local government.
 Earnings – If your earnings change.
 On your application you told us you expect your total nonrailroad earnings for 2012 to be
$25,720.
 Railroad Work – If you go to work for an employer in the railroad industry.
 Employment – If you perform work, including self-employment, for a family owned, controlled or
managed business, including a business operated, managed or owned by you, a family member,
friend or close associate, whether for pay or not, and without regard to how the business is
organized (e.g., sole proprietorship, partnership, corporation, LLC, etc.).
 Employment – If you become a corporate officer of, own or operate a corporation (including
a corporation owned by a family member or friend), whether for pay or not.
 Employment – If you receive anything of value in lieu of salary or wages for any work that you
performed.
 Address – If your address changes, even if your payments are sent to a financial organization.
 Criminal Offense – If you are confined in a jail, prison, penal institution, or correctional facility
due to a conviction for a criminal offense.
 Death or Disability – Your representative should notify the RRB immediately if you die or
become unable to handle your own benefits.
How to Report Changes
When a change occurs after you have begun receiving your annuity, you should report the change
at once. You or your representative can make the reports by telephone, mail or in person,
whichever you prefer.
In most cases, we calculate how much to reduce your annuity because of your earnings based on
either the earnings estimate you gave us when you applied for benefits, or on reports submitted by
employers to the Social Security Administration. As a reminder, you should report your earnings
(1) when we ask for a report of your earnings or (2) if any of the following happens:
RRB Form AA-3sum (11-14)

88552 0215 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0042

 You stop working;
 You start working and expect to earn more than the annual exempt amount;
 Your employment is not covered under the Social Security Act (i.e., FICA taxes are not
deducted from your pay);
 You work for a railroad or railroad labor organization; or
 You return to work for your last pre-retirement nonrailroad employer.
To report any changes or ask questions, you should contact:
U.S. Railroad Retirement Board
Hale Boggs Federal Bldg
Suite 1045
500 Poydras Street
New Orleans LA 70130-3399
877-772-5772
If for some reason you are unable to contact that office, you should contact:
U.S. Railroad Retirement Board
844 N Rush Street
Chicago, Illinois 60611-2092
http://www.rrb.gov

RRB Form AA-3sum (11-14)

88552 0215 22000 06051 32704

Page 4