3220-0031

OMB No. 3220-0031

Justification

Application for Survivor Death Benefits

RRB Forms AA-21, AA-21cert, G-131, and G-273a

1. Circumstances of information collection - Under Section 6 of the Railroad Retirement Act (RRA) (45 U.S.C. 231e), annuities are payable to surviving widow(er)s, children, and certain other dependents. Lump-sum death benefits are payable after the death of a railroad employee only if there are no qualified survivors of the employee immediately eligible for annuities.

With the exception of the lump-sum residual death benefit, eligibility for survivor benefits depends on whether or not the employee was "insured" under the RRA at the time of death. If the deceased employee was not "insured," the jurisdiction of any survivor benefits payable is transferred to and paid by the Social Security Administration (SSA). Regardless of which agency has jurisdiction, the deceased employee's railroad retirement and social security credits are both used for the purpose of benefit computations.

Types of Survivor Benefits

Annuities are payable to widow(er)s and unmarried children. In certain cases, annuities are also payable to dependent parents, remarried widow(er)s, grandchildren, and surviving divorced spouses (OMB No. 3220-0030).

Lump-Sum Death Benefits

If an employee had 10 or more years of railroad service or at least 60 months of railroad service after 1995 and a current connection with the railroad industry, a lump-sum amount may be payable if there is no qualified survivor immediately eligible for an annuity upon the employee's death.

The amount payable depends primarily on whether the deceased employee (1) was credited with 10 years of service prior to January 1, 1975, in which case the average benefit payable is about $800 or (2) completed 10 years of railroad service after 1974, in which case the lump-sum benefit is almost always $255.

• If the employee had 10 years of service prior to 1975, the lump-sum amount is payable to the widow(er) who was either living with or supported by the employee at the time of death. If the employee was not survived by a qualified widow(er), the lump-sum amount may be paid to the funeral home or the payer of the funeral expenses, but the amount paid cannot exceed the actual costs involved.

• If the employee completed 10 years of railroad service after 1974, the lump-sum amount is payable only to a widow(er) who was living in the same household as the employee when the employee died. In certain cases, the husband and wife may be found to have been living in the same household, even though one of them was temporarily away from home.

If in the 12-month period beginning with the month of the employee’s death, an eligible survivor did not, for any reason, receive monthly benefits totaling at least as much as the lump‑sum amount, the difference between the lump-sum amount and the monthly benefits actually paid, if any, is payable to the widow(er) in the form of a deferred lump‑sum benefit.

Residual Lump-Sum Payment

There is an additional death benefit called a residual lump-sum payment, for which an insured status is not required. The amount of the residual lump-sum payment equals the amount of the railroad retirement taxes paid by the employee prior to 1975 plus an allowance for interest. The residual lump-sum payment is reduced for any retirement benefits that have been paid based on the employee's railroad service, and for any survivor benefits previously paid by either the RRB or SSA. In most cases, if an employee received an annuity for two or more years, there is no residual lump-sum payable to his or her survivors.

A residual lump-sum payment cannot be paid if there is an immediate or future monthly survivor benefit payable. However, a widow(er) or parent who would be eligible in the future can, before attaining age 60, elect to waive future rights to monthly benefits in order to receive the residual lump-sum payment.

Once the residual lump-sum payment is made, no further benefits are payable based on the employee's railroad earnings. Furthermore, the widow(er) or parent electing to receive the residual lump-sum payment also gives up rights to Medicare based on the deceased employee's railroad service.

The residual lump-sum payment is made to the employee's widow(er), children, grandchildren, parents, brothers and sisters, or estate, in that order of precedence. However, the employee can change the order of precedence by filing with the RRB, Form AA-11a, Designation or Change of Beneficiary for Employees with Service Prior to January 1, 1975 for Residual Lump Sum.

The requirements for obtaining and for applying for the benefits are prescribed in 20 CFR 217, 219 and 234.

2. Purposes of collecting/consequences of not collecting the information - The RRB uses the following forms to obtain information needed to determine the entitlement to, and amount of, various survivor benefits.

Manual Forms

Form AA-21, Application for Lump-Sum Death Payment and Annuities Unpaid at Death, is used to file for all or any combination of the benefits described above. The manual form is currently divided into ten sections and has one receipt for claim.

• Section 1 gives general instructions on completing the form.

• Section 2 requests identifying information about the deceased employee and the applicant. Six of the seven items in this section are pre-coded by an RRB office before the form and related materials are released to the applicant.

• Section 3 asks for information about the deceased employee that is used to determine the amount of benefits payable, the insured status at the time of death, and the eligibility of the widow(er) for survivor benefits. Survivor benefits are not payable unless the deceased employee had a current connection with the railroad industry. The requested information, along with related data from SSA, allows an RRB claims examiner to make a current connection determination.

• Section 4 gathers information about the widow(er), if one exists. That information is used to establish the widow(er)'s eligibility for the lump-sum death benefit applied for and also to rule out entitlement to monthly benefits in the month in which the employee died.

• Section 5 asks for information about any surviving children and dependent parents, to rule out entitlement to monthly benefits in the month in which the employee died. Section 5 also questions whether the applicant is the living-with widow(er), funeral home representative, child, parent, grandchild, brother/sister, or half-brother/sister, to determine entitlement to the residual lump-sum payment and any annuities unpaid at death.

• Section 6 asks for information about burial expenses. The detailed financial breakdown allows an RRB claims examiner to apportion the amount of the lump sum appropriately in cases where the burial expenses were paid from more than one source.

• Section 7 secures bank account information that allows for benefit payments to be made directly to an annuitant’s bank account.

• Section 8 provides additional space for the continuation of answers to previous questions and/or any additional information that may be relevant.

• Section 9 requests the applicant to certify that all of the information provided on the completed application is correct and that they have received the proper booklets. Section 9 also includes space for two witnesses if the certification is signed by the mark “X.”

• Section 10 describes how to return the application by mail; what items on the application must always be completed; and instructions on what to enclose in the return envelope. Section 10 also notifies the applicant to expect a claim receipt within a month after filing.

• Section 11 provides more detailed instructions and explanations about items on the application such as the various definitions of the word “child” that is referenced in Item 43, and lists the requirements for a “child” to obtain an annuity. Section 11 also describes different types of burial and funeral expenses. Since the definitions are long and take up two pages, the applicant is referred to this section during the process of completing the application.

The form is completed by an RRB representative during an interview with an applicant at their home or is mailed to the applicant for completion, and then returned to the RRB. Once the RRB representative returns to the office or receives a completed form mailed in by the applicant, they enter the information from the form into the on-line Application Express (APPLE) system.

The RRB proposes to add the RRB headquarters mailing address in Section 10, How to Return Your Application, of Form AA-21 in order to provide address information for returning completed forms.

Form G-131, Authorization of Payment and Release of All Claims to a Death Benefit or Accrued Annuity Payment, is mailed at the request of an eligible person who expresses a desire to assign his or her share of the death benefit or unpaid annuities to another eligible applicant providing the share does not exceed $500. The approximate amount of the share to the eligible person is entered on the form by the RRB before it is mailed to the applicant.

Form G-131a, which is used as a transmittal letter for the G-131 contains the approximate amount of the share and other important respondent information.

The RRB proposes no changes to Form G-131.

Form G-273a, Funeral Director's Statement of Burial Charges, is completed by the director of the funeral home who arranged the employee's funeral. The form has the following three functions:

• It serves as proof of death except when the director of the funeral home is applying for the lump sum;

• It provides proof of the total amount of funeral home expenses, the amount of funeral home expenses which have been paid, and identification of the individual who paid the expenses; and

• It is used to certify that the funeral director will return any over-reimbursement to the RRB.

The RRB proposes to add the RRB headquarters mailing address to the last sentence of the second paragraph of Form G-273a above Item 1, Date of Death, in order to provide address information for returning completed forms.

Electronic Form

The on-line equivalent version of Form AA‑21, Form AA-21cert, Application Summary and Certification is automated through the RRB’s APPLE system. The on-line process is used when an RRB representative interviews an applicant at an RRB field office (preferred), an itinerant point, or by telephone then enters the information directly into the APPLE system.

The AA-21cert collects essentially the same information as the manual AA-21, however, it consists of a script or a series of questions. Depending on the responses to the questions, the APPLE system automatically generates the next appropriate question, eliminating the confusion associated with skip patterns (“go to items”) that are on the paper version. The APPLE system automatically pre-fills identifying information in real time from RRB database records onto the on-line screens. The direct entry of the interview data into the APPLE system expedites the payment process, thereby enhancing RRB customer service goals.

Form AA-21cert is generated by the APPLE system upon completion of the on-line AA-21 application process for the applicant to review the information provided or verified, and sign with a traditional pen-and-ink “wet” signature. If the application interview is taken over the telephone, the AA-21cert is mailed to the applicant for review and signature. The RRB does not release the application for processing by the payment systems until the signed AA-21cert is returned by the applicant.

Form AA-21cert is divided into three parts:

• Part 1 summarizes information about the employee.

• Part 2 summarizes information about the applicant.

• Part 3 asks the applicant to certify the responses provided during the interview by signing the application. The certification language includes statements that the information given in relation to the application is true; and that the applicant (1) received and reviewed a summary of the information; (2) received the correct booklets; 3) is obligated to advise the RRB of any errors in that summary; and (4) knows that making a false or fraudulent statement is committing a crime under Federal law, which is punishable by fines, imprisonment, or both.

A footer on each page includes the form number, the page number, and a unique identifier. The unique identifier consists of the employee’s social security number, the application type code and the time and date of generation.

After the application is released, Form AA-21rec is provided to the applicant as a receipt, advising that processing of the application has begun. The receipt also provides a general description of the application process as well as the telephone numbers of both the field office and headquarters if there are changes to be reported.

The Paperwork Reduction Act and Privacy Act Notices associated with the AA-21 and AA‑21cert application process are included in RRB booklet RB-21, Lump-Sum Death Payment, Residual Lump-Sum, Annuities Unpaid at Death.

NOTE: The RRB submitted two versions of the Form AA-21cert in ROCIS. One version contains all possible questions. The other version is an example of a completed application, which includes only statements relevant to that application. The annuitant and any personally identifiable information contained in these two versions are fictitious.

The RRB proposes no changes to Form AA-21cert.

3. Planned use of improved information technology or technical/legal impediments to further burden reduction – While we have used information technology (the APPLE, Application Express system, which has largely automated the lump-sum application process) to enhance this collection to reduce the burden on applicants, budgetary and technology constraints prevent us from making further technological improvements at this time. However, we will reevaluate after the completion of the RRB IT Modernization project.

4. Efforts to identify duplication - Form AA-21 is similar to and combines information from Form

SSA-8-F4 (0960-0013) and Form SSA-1724-F4 (0960-0101). Form G-273a is comparable to the SSA-721 (0960-0142). SSA has no form similar to Form G-131.

5. Small business respondents - N.A.

6. Consequences of less frequent collection - N.A.

7. Special Circumstances – None

8. Public comments/consultations outside the agency - In accordance with 5 CFR 1320.8(d), comments were invited from the public regarding this information collection. The notice to the public was published on page 8619 of the February 15, 2022, Federal Register. No comments or requests for additional information were received from the public.

9. Payments or gifts to respondents – N.A

10. Confidentiality - Privacy Act System of Records RRB-22, Railroad Retirement, Survivor and Pension Benefit System. In accordance with OMB Circular M-03-22, a Privacy Impact Assessment for this information collection was completed and can be found at https://www.rrb.gov/sites/default/files/2017-06/PIA-BPO.pdf.

11. Sensitive questions - N.A.

12. Estimate of respondent burden – The current burden for the information collection is as follows:

Current Burden

Form Number	Annual Responses	Time (Minutes) 1/	Burden (Hours)
AA-21cert with assistance	3,500	20	1,167
AA-21 without assistance	200	40	133
G-131	100	5	8
G-273a	4,000	10	667
Total	7,800		1,975

1/The RRB has been collecting the information on these forms since OMB approved the information collection. Based on a sampling done when the form was originally created, the office calculated the estimated time, which includes time for getting the needed data and reviewing the completed form.

13. Estimated annual cost to respondents or record keepers - N.A.

14. Estimated cost to the Federal Government - N.A.

15. Explanation for change in burden – N.A.

16. Time schedule for data collections and publication - The results of this collection will not be published.

17. Request not to display OMB expiration date - The RRB started an extensive multi-year IT Modernization Initiative at the beginning of Fiscal Year 2019 to transform our operations into the 21^st Century using multiple contractor services to improve mission performance, expand service capabilities, and strengthen cybersecurity. We provided OMB with a consolidated project timeline.

Given that the forms in this collection are seldom revised; the costs associated with redrafting, reprinting, and distributing forms in order to keep the appropriate OMB expiration date in place; and our desire to reevaluate after the completion of the modernization project, the RRB requests the authority to not display the expiration date on the forms.

18. Exceptions to Certification Statement - None

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