AA-21 - Application for Survivor Benefits - Receipt for Claim

Proposed Completed

United States of America
Railroad Retirement Board

Form AA-21rec (10-18)

Application for Survivor Benefits - Receipt for Claim
Jane Public
7918 W 618 St
Lake Lagoon Fl
161516
Employee’s Name

John Public

Application Filing Date

April 19, 2018

Your application for a Lump Sum Death Payment has been released and will be processed as
quickly as possible. If you do not receive notification about your application by June 24, 2018
you should contact the field office shown below.
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.
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, Tuesday, Thursday, Friday and 9:00 AM
to 12:00 PM Wednesday. To report any changes or ask questions, you should contact:
US Railroad Retirement Board
Timberlake Federal Building
Suite 300
500 E Zack St
Tampa FL 33602-3918
877-772-5772
If for some reason you are unable to contact that office, you should contact:
US Railroad Retirement Board
844 N Rush Street
Chicago, Illinois 60611-1275
http://www.rrb.gov