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United States of America
Railroad Retirement Board
Form Approval
OMB NO. 3220-0031
Do Not Write in This Space
OFFICIALLY FILED
Day
Month
OFFICE NUMBER
Year
Application for Lump-Sum
Approved
Death Payment and
Annuities Unpaid at Death
APPLICATION
DATE CODED
Month
Day
Year
Coded By
Section 1
General Instructions
Before you complete this application, be sure to read the booklet RB-21, Lump-Sum Death Payment, Residual Lump-Sum, and
Annuities Unpaid at Death, which explains information you will need to answer many of the questions in this application.
Please be sure to read the important notices on the inside covers of the RB-21 booklet. Type or print legibly in ink. If you need more
space than is provided to answer a question, use Section 8, Remarks, for this purpose. If you do not know the answer to a question,
print “Unknown” in the space provided for the answers. When entering dates, always use numbers. Also, be sure there is one number in each box. For example, you would enter September 25, 2018 as:
Month
Day
Year
0 9 2 5 2 0 1 8
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 the Railroad Retirement Board (RRB) in Items 1 through 6 for accuracy.
If the information is correct, go to Item 7.
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
Applicant
Identification
1
Employee’s Name
2
Employee’s Social Security Number
4
Applicant’s Name NOTE: If representative of funeral home, enter funeral home’s name, representative’s name and representative’s title.
5
a Mailing Address NOTE: If representative of funeral home, enter funeral home address.
5
b City and State
5c ZIP Code
6
Daytime Telephone Number (include area code)
7
3
Employee’s Railroad Retirement Claim Number (Include Prefix)
5d County
Applicant’s social security number. If none, enter “NONE.”
NOTE: Do not complete if you are the funeral home director.
Form AA-21 (12-18) Destroy Prior Editions
Section 3
Information About The Employee
If a railroad retirement survivor benefit was previously received by someone, go to Section 5; otherwise go to Item 8.
Birth Date
8
Enter the employee’s date of birth.
Residence
9
Enter the state (or country if other than
United States) which was the employee’s
permanent home at the time of death.
Military
Service
Month
Day
Year
Please read the chapter “Credit for Military Service” in the RB-21 booklet to find out how active military service is determined.
10 Enter an “X” in the appropriate box:
The employee was in active military service after September 7, 1939.
Yes
Go to Note and Item 11
No
Go to Item 13
Note: If answered “Yes,” and proof of the employee’s military service is not already in
our file, you may be requested to provide it. We will notify you if proof is needed.
Disability
11 Enter an “X” in the appropriate box:
The employee had voluntary military service during the period
June 15, 1948, through December 15, 1950.
12 Enter an “X” in the appropriate box:
The employee had nonrailroad earnings after leaving the
military service and before returning to the railroad.
Yes
Go to Item 12
No
Go to Item 13
Yes
No
If the employee died at 62 or older, go to Item 14.
13 Enter an “X” in the appropriate box:
The employee was unable to work at the time of death because of an
illness or accident which occurred at least five months before death.
Recent
Employment
Yes
No
14 Regardless of whether the employee was retired at death, enter the name and address of each railroad or nonrailroad
employer for whom the employee performed any part-time or full-time work during the last three years. Enter the name
and address of the most recent employer in 14a, the second in 14b, and so on. Enter the date each job began and
ended. If you need additional space, continue in Section 8.
Name and Address of Employer
a
Name
Began
Address
Month
Year
Ended
Month
Year
City, State, and ZIP Code
b Name
Began
Address
Month
Year
Ended
Month
Year
City, State, and ZIP Code
c
Name
Began
Address
Month
Year
Ended
Month
City, State, and ZIP Code
SelfEmployment
15 Enter an “X” in the appropriate box:
The employee was self-employed during any
of the last three calendar years.
16 Enter an “X” in the appropriate box:
The employee’s net earnings from self-employment were
more than $400 in any of the last three calendar years.
Form AA-21 (12-18)
Page 2
Yes
Go to Item 16
No
Go to Item 18
Yes
Go to Item 17
No
Go to Item 18
Year
SelfEmployment
(Continued)
Railroad
Employment
This Year
17 Enter an “X” in the appropriate box(es) to show the
year or years in which the employee’s net earnings
from self-employment were more than $400.
18 Enter an “X” in the appropriate box:
The employee was alive on October 1, 1981, AND
had at least 25 years of railroad service.
Last Year
Year before last
Yes
Go to Note and Item 19
No
Go to Item 21
Note: Please read the chapter “Requirements the Employee Must Have Met” in the
RB-21 booklet to find out what special conditions may apply if the employee was alive on
October 1, 1981, and had at least 25 years of railroad service.
19 Enter an “X” in the appropriate box:
The employee “involuntarily and without fault”:
• stopped working for his or her last railroad employer
on or after October 1, 1975, or
• was on furlough, leave of absence status, or absent
because of injury on October 1, 1975, and was never
called back to work for that employer.
20 Enter an “X” in the appropriate box:
The employee declined an offer from a railroad employer
to return to a job in the same “class or craft” as his or her
last railroad job.
Yes
Go to Item 20
No
Go to Item 21
Yes
Go to Item 21
No
Go to Note and Item 21
Note: You may be requested to submit proof to verify the statements in Items 19 and 20.
Employee’s
Marriages
21 Enter an “X” in the appropriate box:
Was the employee ever married?
Yes
Go to Item 22
No
Go to Section 5
22 Enter the requested information for each of the employee’s marriages. Enter the most recent marriage in 22a, the second
most recent in 22b, and so on. If the employee was married only once, enter the information in 22a, and go to Item 23.
Name of
Employee’s
Wife or Husband
(If wife, include
maiden name)
a
Date Married
Month
Day
City and State
Married
(Country,
if other
than U.S.)
Answer if Marriage Ended for Reason
Other than Employee’s Death
How Marriage
Ended
(Check one)
Date Marriage
Ended
Employee’s Death Month
Spouse’s Death
Year
Day
Year
Day
Year
Day
Year
City and State
Marriage Ended
(Country, if other
than U.S.)
Divorce
Annulment
b
Month
Day
Employee’s Death Month
Spouse’s Death
Year
Divorce
Annulment
c
Month
Day
Employee’s Death Month
Spouse’s Death
Year
Divorce
Annulment
23 Enter an “X” in the appropriate box:
At least one of the employee’s marriages lasted
for ten years and ended in divorce.
Yes
Go to Note and Item 24
No
Go to Section 4
Note: If more than one marriage fits this description, use Section
8 to answer Items 24-28 for each marriage.
Page 3
Form AA-21 (12-18)
Employee’s
Marriages
(Continued)
24 Enter an “X” in the appropriate box:
The divorced spouse was alive in the month the employee died.
25 Divorced spouse’s date of birth.
26 a Enter an “X” in the appropriate box:
The divorced spouse has remarried.
Yes
Go to Item 25
No
Go to Section 4
Month
Yes
No
Day
Go to Item 26b
Go to Item 28
Month
b
Year
Day
Year
Divorced spouse’s date of birth.
27 a Enter an “X” in the appropriate box:
The marriage has ended.
Yes
Go to Item 27b
No
Go to Item 28
Month
b Date the marriage ended.
Day
Year
28 a Divorced spouse’s name.
b Divorced spouse’s social security number.
c
Mailing Address
d City and State
28e ZIP Code
g Daytime Telephone Number (include area code)
Section 4
Widow(er)
Widow(er)’s
Birthdate
Widow(er)’s
Disability
Support
28f County
(
)
Information About The Widow(er)
29 Enter an “X” in the appropriate box:
The employee was survived by a widow(er).
30 Widow(er)’s date of birth.
31 Enter an “X” in the appropriate box:
The widow(er) was age 50-59 in the month the employee died.
32 Enter an “X” in the appropriate box:
In the month the employee died, the widow(er) was unable to
work due to an accident or illness.
33 Enter an “X” in the appropriate box:
The widow(er) is still alive.
34 Enter an “X” in the appropriate box:
The employee and the widow(er) were living together
when the employee died.
35 Enter the date the widow(er) and the employee
stopped living together.
No
Go to Item 30
Go to Section 5
Month
Yes
Go to Item 32
No
Go to Item 33
Year
Yes
Yes
Go to Item 34
No
Go to Section 5
Yes
Go to Item 39
No
Go to Item 35
Month
Page 4
Day
No
36 Enter the reason(s) the widow(er) and the employee stopped living together.
Form AA-21 (12-18)
Yes
Day
Year
Support
(Continued)
Name at
Birth
Widow(er)’s
Marriages
37 Enter an “X” in the appropriate box:
The employee was making regular contributions to the
widow(er)’s support when the employee died. (Consider the
following as contributions to support: money, food, clothes,
paying bills, providing rent-free housing.)
38 Enter an “X” in the appropariate box:
The employee was under a court order to contribute to the
widow(er)’s support. (Note: Answer “Yes” if there was a
court order, even if the employee was not obeying it.)
39 Enter an “X” in the appropriate box:
I am the employee’s widow(er).
40 Enter your name at birth.
41 Enter an “X” in the appropriate box:
I am now, or was previously, married to someone
other than the employee.
Yes
Go to Item 39
No
Go to Item 38
Yes
No
Yes
Go to Item 40
Go to Section 5
No
Yes
Go to Item 42
No
Go to Section 5
42 Enter the requested information for each of your marriages to someone other than the employee.
Enter your spouse’s name at birth and social security number (SSN). If the SSN is unknown, provide the date and place of
birth of the spouse and the name at birth of both parents of the spouse in Section 8.
Enter the most recent marriage in 42a, the second most recent in 42b, and so on.
a Spouse’s Name
Social Security Number
City and State
Married
(Country,
if other
than U.S.)
Date Married
Month
Day
How Marriage
Ended
(Check one)
Spouse’s Death
Divorce
Annulment
Year
b Spouse’s Name
Month
Day
Year
How Marriage
Ended
(Check one)
Spouse’s Death
Divorce
Annulment
c Spouse’s Name
Month
Day
Year
Day
Year
Date Marriage
Ended
Month
Day
City and State
Married
(Country,
if other
than U.S.)
Year
Social Security Number
City and State
Married
(Country,
if other
than U.S.)
Date Married
Month
Social Security Number
City and State
Married
(Country,
if other
than U.S.)
Date Married
Date Marriage
Ended
City and State
Married
(Country,
if other
than U.S.)
How Marriage
Ended
(Check one)
Spouse’s Death
Divorce
Annulment
Page 5
Date Marriage
Ended
Month
Day
City and State
Married
(Country,
if other
than U.S.)
Year
Form AA-21 (12-18)
Section 5
Child’s
Annuity
Information About The Employee’s Family
43 Enter an “X” in the appropriate box:
There is a “child,” as defined in Section 11, who
may be eligible for an annuity.
Yes
Go to Item 44
No
Go to Item 45
Note: An eligible “child” includes but is not limited to any currently unmarried, natural,
adopted, step, or (in certain instances) grandchild of the deceased employee who, in the
month the employee died, was:
• Under age 18, or
• Age 18-19 AND attending high school full time, or
• ANY AGE as long as the “child” was totally and permanently disabled BEFORE the
child obtained age 22.
For a complete explanation of the circumstances in which a “child” may be eligible for an
annuity, see Section 11.
44 Provide the information requested below for the child(ren) referred to in Item 43.
Child’s Full Name
Legal Relationship
(Check One)
a
Child’s Full Name
Child’s Full Name
c
Address
Telephone Number (include area code)
(
Legal Relationship
(Check One)
b
Natural
Stepchild
Legally Adopted
Equitably Adopted
Deemed
Grandchild
Stepgrandchild
Address and Telephone Number
Natural
Stepchild
Legally Adopted
Equitably Adopted
Deemed
Grandchild
Stepgrandchild
Address and Telephone Number
Address
Telephone Number (include area code)
(
Legal Relationship
(Check One)
Natural
Stepchild
Legally Adopted
Equitably Adopted
Deemed
Grandchild
Stepgrandchild
)
)
Address and Telephone Number
Address
Telephone Number (include area code)
(
45 Enter an “X” in the appropriate box:
The deceased employee was female.
46 Enter an “X” in the appropriate box:
A child of employee is expected to be born.
)
Yes
Go to Item 48
No
Go to Item 46
Yes
Go to Item 47
No
Go to Item 48
47 Enter month and year child is expected.
Parent’s
Annuity
Month
48 Enter an “X” in the appropriate box:
The employee was survived by a parent.
49 Enter an “X” in the appropriate box:
The parent was dependent on the employee for one-half support.
Form AA-21 (12-18)
Page 6
Yes
Go to Item 49
No
Go to Item 51
Yes
Go to Item 50
Go to Item 51
No
Year
Parent’s
Annuity
(Continued)
50 Enter the requested information for each dependent parent of the employee.
a Name of Parent
Date of
Birth
Month
Year
Month
Year
Address and Telephone Number (include area code)
b Name of Parent
Date of
Birth
Address and Telephone Number (include area code)
Information
About
Applicant
Children
51 Enter an “X” in the appropriate box:
I am the employee’s widow(er) and I was living with
the employee when the employee died.
52 Enter an “X” in the appropriate box:
I am completing this application as a representative
of a funeral home.
53 Enter an “X” in the appropriate box:
I am the employee’s natural child, legally adopted child,
equitably adopted child, deemed child, parent, grandchild,
brother, sister, half-brother or half-sister.
Yes
Go to Section 7
No
Go to Item 52
Yes
Go to Section 7
No
Go to Item 53
Yes
No
Go to Item 54
Go to Section 6
54 Enter the requested information for any surviving child(ren) of the employee (except stepchild(ren)) not listed in Item 44.
Name of Child
(If none, enter “NONE”)
Legal Relationship
(Check One)
a
Natural
Legally Adopted
Equitably Adopted
Deemed
b
Natural
Legally Adopted
Equitably Adopted
Deemed
c
Address and Telephone Number (include area code)
Natural
Legally Adopted
Equitably Adopted
Deemed
Note: If any child is listed above, go to Section 6.
GrandChildren
55 Enter the requested information about the surviving grandchild(ren) of the employee not identified in Item 44 (except a
stepgrandchild) no matter how old they are, what their marital status is, and regardless of whether the employee was
supporting them.
Name of Grandchild
Name at Birth
Address and Telephone Number (include area code)
(If none, enter “NONE”)
of Parents
Father
a
Mother
Father
b
Mother
Page 7
Form AA-21 (12-18)
Name of Grandchild
(If none, enter “NONE”)
GrandChildren
(Continued)
55
Name at Birth
of Parents
Address and Telephone Number (include area code)
Father
c
Mother
Father
d
Mother
Note: If any child is in Item 55, go to Section 6.
Brothers
and
Sisters
56
Enter the employee’s surviving brothers, sisters, half-brothers and half-sisters. Do Not include stepbrothers or
stepsisters. If you need additional space, continue in Section 8.
Name (If none, enter “NONE”)
Address and Telephone Number (include area code)
a
b
c
d
Section 6
Information About Burial Expenses
See Section 11 for additional instructions before answering questions in Section 6.
Funeral
Home
Expenses
Assumption
of
Responsibility
57 Enter the total amount of funeral home expenses.
58 Enter the amount of funeral home expenses paid with
your own money.
(If none, check box.)
59 Enter the amount of funeral home expenses paid with the
employee’s money.
(If none, check box.)
60 Enter the amount of funeral home expenses paid with any
other person’s money.
(If none, check box.)
61 Enter the amount of funeral home expenses which are still
not paid.
(If none, check box.)
$
$
None
$
None
$
None
$
None
If “None,” go to Item 66
The RRB considers that a person has assumed responsibility for unpaid funeral home expenses if either the person has paid
some portion of the total funeral home expenses, or there is an agreement between the person and the funeral home about
how the expenses will be paid.
62 Enter an “X” in the appropriate box:
I have assumed responsibility for the funeral home
expenses which are not paid.
63 Enter an “X” in the appropriate box:
Some other person or organization has assumed responsibility
for the funeral home expenses which are not paid.
Form AA-21 (12-18)
Page 8
Yes
Go to Item 65
No
Go to Item 63
Yes
Go to Item 64
No
Go to Item 66
Assumption
of
Responsibility
(Continued)
64
Enter the full name of the person or organization who assumed responsibility then go to Item 66.
Name
Telephone Number (include area code)
Address
(
Authorization
to Funeral
Home
65
)
If any of the funeral home expenses are unpaid, the lump-sum death payment (or a part of the lump-sum death
payment equal to the amount of the unpaid funeral home expenses) can only be paid to the funeral home.
However, before this payment can be made, you must authorize the RRB to make the payment.
I request the RRB to pay the lump-sum death payment to:
Name of funeral home
Telephone Number (include area code)
Address of Funeral Home
(
)
Note: If there are unpaid funeral home expenses at more than one
funeral home, show the name, address, and telephone number of the other
funeral home(s) in Section 8.
Opening
and Closing
of Grave
66 Enter the total amount of the cost of opening and closing
the grave not included in Item 57.
(If none, check box.)
$
None
If “None,” go to Item 70
When answering Items 67-77, consider any money you received from a life insurance policy or other death benefit
as your own if you were named as the beneficiary for the policy or benefit. Also, consider money from any bank
account as your own if you were one of the joint owners of the account.
Burial
Plot
67 Enter the amount of the grave opening and closing costs
paid with your own money.
(If none, check box.)
$
None
68 Enter the amount of the grave opening and closing costs
paid with the employee’s money.
(If none, check box.)
$
None
69 Enter the amount of the grave opening and closing costs
paid with any other person’s money.
(If none, check box.)
$
None
70 Enter the total amount of the cost of the burial plot not
included in Item 57.
(If none, check box.)
$
None
If “None,” go to Item 74
71 Enter the amount of the burial plot paid with your
own money.
(If none, check box.)
$
None
72 Enter the amount of the burial plot paid with the
employee’s money.
(If none, check box.)
$
None
73 Enter the amount of the burial plot paid with any
other person’s money.
(If none, check box.)
$
None
Page 9
Form AA-21 (12-18)
Other
Burial
Expenses
74 Enter the amount of other burial expenses not
included in Item 57.
(If none, check box.)
$
None
If “None,” go to Item 78
Other
Federal
Allowances
75 Enter the amount of other burial expenses paid
with your own money.
(If none, check box.)
$
None
76 Enter the amount of other burial expenses paid
with the employee’s money.
(If none, check box.)
$
None
77 Enter the amount of other burial expenses paid
with any other person’s money.
(If none, check box.)
$
None
78 Enter an “X” in the appropriate box:
An application for a burial allowance has been, or will
be, filed with the Department of Veterans Affairs or other
Federal Agency.
Yes
Go to Item 79
No
Go to Item 80
79 Enter the requested information about who the application for a burial allowance has been, or will be, filed with.
Agency
Name of Person Filing with Agency
Amount
Department of Veterans Affairs
$
Other Federal Agency (Specify)
$
Reimbursement
If you did not pay any of the burial expense, go to Item 82.
When answering Items 80 and 81, DO NOT consider any money you received from a life insurance policy or other
death benefit if you received the money because you were named beneficiary for the policy or benefit. DO NOT
consider any money from any bank account if you were one of the joint owners of the account. Also, DO NOT consider
any money, goods, or property that you inherited from the employee under the provisions of a valid will or applicable
state law.
80 Enter an “X” in the appropriate box:
I have received, or I will receive, money or property
(real estate or other goods) to pay me back for the
burial expenses I paid.
Yes
Go to Item 81
No
Go to Item 82
81 Enter the requested information for each source of payment to you.
Source of Money or Property
Date Received or Expected
Amount of Value
$
$
$
Estate
82 Enter an “X” in the appropriate box:
A court appointed administrator or executor has been
appointed. (Answer “No” if someone has been named
in the employee’s will only.)
Form AA-21 (12-18)
Page 10
Yes
Go to Item 83
No
Go to Item 84
Estate
(Continued)
83 Enter the requested information about the administrator or executor.
a Name
(If applicant, enter “SELF” and go to Item 84)
b Address
c Telephone Number (include area code)
Other
Payers of
Burial
Expenses
(
)
84 Answer only if any other person or organization paid any of the burial expenses.
Enter the requested information for each source who paid expenses.
Name, Address, and Telephone Number
of Person or Organization
Type of Burial Expenses
(Check One)
a
b
c
d
Section 7
Amount
Funeral Home
Grave Opening/Closing
Burial Plot
Other
$
Funeral Home
Grave Opening/Closing
Burial Plot
Other
$
Funeral Home
Grave Opening/Closing
Burial Plot
Other
$
Funeral Home
Grave Opening/Closing
Burial Plot
Other
$
Direct Deposit
Do not complete this section if your account is at a foreign bank.
Benefits are normally paid by Direct Deposit to your bank, savings and loan, credit union, or other financial institution. To
Direct
provide the information we need to correctly deposit your payments, attach a voided personal check and go to Section 8,
Deposit
or call your financial institution for the information you need to complete Items 85-89. If you do not have a bank account, or
receiving your payments by Direct Deposit causes you a hardship, go to Item 90.
85 Print the name of your financial institution.
86 Print the telephone number (including area
code) for your financial institution.
87 Print the routing transit number
of your financial institution.
88 Print your account number.
(
)
89 Enter an “X” in the appropriate box:
Type of account for the above account
number.
Checking
Savings
Go to Section 8
90 Check this box if you do not have a checking or savings
account, or if Direct Deposit would cause you a hardship.
Page 11
Form AA-21 (12-18)
Section 8
Remarks
Remarks
91 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 section to enter any additional information
that you feel may be important to include.
Form AA-21 (12-18)
Page 12
Section 9
Certification
Certification
92 I know that if I make a false or fraudulent statement in order to receive benefits from the Railroad Retirement Board (RRB),
I am committing a crime which is punishable under Federal law.
If I receive the lump-sum death payment because I paid the employee’s burial expenses, I also agree not to request or
accept reimbursement from another party for that part of the burial expenses for which I am reimbursed by
the lump-sum death payment.
I have received the appropriate application booklet.
I certify that the information I gave to the RRB on this application is true to the best of my knowledge.
Signature
(First Name, Middle Initial,
Last Name)
Date
Month
Day
Year
93 If this application is signed by mark (“X”) in Item 92, 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)
(
)
(
)
b Signature of Witness
Address (Number and Street)
City, State, and ZIP Code
Daytime Telephone Number (include area code)
Section 10
How to Return Your Application
Before you return your application, check to make sure that:
• Every question that applies to you has been answered.
• You have entered “Unknown” in any question space for which you were unable to answer the question.
• You have signed and dated the application.
• You have included all the needed proofs listed in the letter you received with this application.
When you receive 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 shown on the last page 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:
• Needed proofs
• The application itself
• Additional forms you were asked to complete
Note: A receipt for your application will be sent to you after the RRB receives your completed and signed application.
When you receive the receipt, 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 your receipt within a month after you filed this application,
please contact us so we can find out what is causing the delay.
Page 13
Form AA-21 (12-18)
Section 11
Additional Instructions
This section contains more detailed instructions or explanations for a few of the items on the application form. Whenever
the instructions on the Form AA-21 refer you to Section 11, you should read this section for the particular question or section
before you complete that part of the application. This section can be detached from the Form AA-21 packet before the
application is returned to the Railroad Retirement Board (RRB).
Item 43
The RRB may be able to pay an annuity to a child of a deceased employee if the child meets certain requirements. When
we use the word “child,” we are including all of the following categories of children:
• Natural child
.
• Stepchild
• Legally adopted child
• Equitably adopted child (that is, the employee intended to adopt the child but a legal adoption was not complete
before the employee died)
• Deemed child (that is, a child who is born during an invalid marriage)
• Grandchild
• Stepgrandchild
In order to be considered for an annuity, the child must be unmarried. In addition, the child must be:
• under age 18; or
• age 18 or older and became disabled before age 22 and the disability is not expected to ever go away; or
• age 18-19 and is attending high school full time.
If the child is the employee’s stepchild, the employee must have been providing at least one-half support. If the child is the
employee’s grandchild or stepgrandchild, the employee must have been providing at least one-half of the child’s support
and either the child’s own parents were dead or disabled or the child was legally adopted by the employee’s widow or
widower.
Even if there are no children who meet these requirements right now, a child’s annuity may be able to be paid if any child
met all the requirements in the month the employee died or later or, if the employee died more than six months ago, if any
child met these requirements anytime in the last six months.
If there is any child who meets these requirements, put an “X” in the “YES” box. In addition, you, some other adult acting for
the child, or the child should contact the RRB as soon as possible and request information about childrens’ annuities.
Section 6 (Items 57-84)
Section 6: Information About Burial Expenses requires various information about the types of burial expenses which have
resulted from the employee’s death and about the people who paid these expenses and the money which was used to pay
the expenses. Please refer to the following definitions when completing Items 57-84.
• Burial Expenses
Burial expenses include any expenses which arose in connection with the burial or cremation of the employee’s
body. These include the burial plot, casket, clothing, cremation, death certificates, embalming, flowers, hearse and
car for funeral procession, minister, monument, newspaper notice, niche, opening and closing of grave, permits,
perpetual care of grave, preparation of body for burial, religious services, telegrams, telephone calls, transportation
of the body, traveling expenses of the person escorting the corpse or completing burial arrangements, and so on.
• Funeral Expenses
Funeral expenses include any of the above burial expenses if the expense is incurred by or through the funeral home.
In other words, any burial expense which is included in the funeral home’s charges is considered a funeral expense.
• Burial Plot Cost
The cost of the burial plot is the value of the plot at the time the employee is buried, even if the plot was purchased
before the employee’s death. If the plot in which the employee is buried is part of a multiple plot, only the portion of
the value of the plot which corresponds to the portion of the plot in which the employee is buried is considered the
burial plot cost.
Continued on Page 15
Form AA-21 (12-18)
Page 14
Continued from Page 14
• Other Burial Expenses
Any burial expense which is not included in the funeral home’s charges, is not the cost of opening and closing of the
grave and is not the burial plot cost can be included in the total other burial expenses.
• Your Own Money
You should consider that you paid expenses with your own money if the money used to pay the expenses was:
•
•
•
•
•
Your own personal funds.
Money from a joint bank account owned by you and the employee.
Money from an insurance policy if you were the beneficiary of the policy.
A death benefit from a fraternal association, union, or employer if you were named beneficiary of the benefits.
Money paid by an institution, organization, or association of which you are applying as the representative.
• The Employee’s Money
No matter who makes the actual payment, consider that burial expenses were paid with the employee’s money if the
money used to make the payment was:
•
•
•
•
•
•
cash which the employee had at death;
money which was in a bank account which was owned by the employee;
money obtained by selling any of the employee’s property;
unpaid wages which an employer was holding;
money from a trust fund or money from an insurance policy which the employee owned, if there was no
beneficiary or if all the beneficiaries died before the employee; or
any payment made to a funeral home by the employee prior to the employee’s death as part of a pre-need
burial plan.
• Other Person’s Money
Any portion of the burial expenses which has been paid using funds other than those considered to be your own
money or the employee’s money should be shown as expenses paid with any other person’s money. The term
“person” can be applied to an individual, partnership, organization, fraternal association or government unit.
• Reimbursement
The lump-sum death payment may be paid as a reimbursement to the person(s) who paid the employee’s burial
expenses. An individual who receives the lump-sum death payment on this basis agrees not to request or accept
reimbursement from another party for that part of the burial expenses reimbursed by the lump-sum death payment.
You must submit proof of payment of the burial expenses. Part V of the booklet RB-21, Lump-Sum Death Payment,
Residual Lump-Sum, and Annuities Unpaid at Death, explains what proof is acceptable. If there are certain expenses
such as flowers, telegrams, phone calls or payments for a religious ceremony for which you did not receive a receipt, use
Section 8 to list the expenses and the amount of each expense.
Note: If you are applying on behalf of a medical school, dental school, or
anatomical board, use Section 8 to show the date of final disposition of the
employee’s body (that is, the date when the body was buried or when the
ashes from the cremation were scattered or otherwise put to rest). If there
has been no final disposition of the body, indicate that in Section 8.
Page 15
Form AA-21 (12-18)
| File Type | application/pdf |
| File Title | AA-21 (10-18).indd |
| Author | boydleo |
| File Modified | 2018-12-11 |
| File Created | 2018-11-02 |