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pdfUNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD
FORM APPROVED
O.M.B. No. 3220-0030
DO NOT WRITE IN THIS SPACE
OFFICIALLY FILED
MONTH
DAY
APPLICATION FOR
DETERMINATION
OF WIDOW(ER)’S
DISABILITY
YEAR
OFFICE NUMBER
APPROVED
APPLICATION NUMBER
DATE CODED
DAY
MONTH
YEAR
CODED BY
General Instructions
Section 1
Before you complete this application, be sure to read Part 1 of booklet RB-17b, Widow(er)’s Disability Benefits, which explains
information you will need to answer many of the questions in this application. Please read “Important Notices” on page 12 of this
application.
Print legibly in ink. If you need more space than is provided to answer a question, use Section 9 remarks for this purpose. If you do not
know the answer to a question, print “unknown” in the space provided for the answer.
When entering dates, always use numbers. Also, be sure there is one number in each box. For example, you would enter December 13,
2021, as:
Month
Day
Year
1 2 1 3 2 0 2 1
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) for Items 1 through 6 for accuracy.
u If the information is correct, go to Section 3.
u If the information is not correct, enter the correct information.
u If the information is missing, fill it in.
Employee
Identification
Applicant
Identification
1
EMPLOYEE’S NAME
2
EMPLOYEE’S SOCIAL SECURITY NUMBER
3
EMPLOYEE’S RAILROAD RETIREMENT CLAIM NUMBER
4
APPLICANT’S NAME
5
a
APPLICANT’S
STREET ADDRESS
b
CITY AND STATE/
PROVINCE
c
ZIP CODE
d
COUNTRY
a
DAYTIME TELEPHONE NUMBER
b
ALTERNATE TELEPHONE NUMBER
6
Form AA-17b (06-19) Destroy Prior Editions
Section 3
Medical
Condition
7
Information About Your Medical Condition
Describe the medical condition(s) causing you to file. Enter the exact primary diagnosis if known and any
additional condition(s). Also enter if no medical records are being forwarded for each condition described.
Primary Condition
Medical Attached
q Yes
q No
Additional Condition(s)
Medical Attached
When
Condition
Began
8
Enter the date the condition began to affect your ability to
work.
How
Condition
Affects
Work
9
Enter an “X” in the appropriate box:
Have you worked since the date in Item 8?
10
Enter an “X” in the appropriate box:
Has your condition caused you to change:
Your job duties?
Your hours of work?
Your attendance?
Anything else about your work?
11
Current
Work
Status
q Yes
q No
q
q
q
q
No
Year
Go to Item 10
Go to Item 12
Yes
DATES
12
Enter the date you could no longer work because of your
condition(s).
13
Describe how your condition(s) prevents you from working.
14 a
Enter an “X” in the appropriate box:
Did you attempt to go back to work and were
you unable to do so?
b
Section 4
Medical
Care or
Examination
Day
q
No
If ”Yes” to
any item, go
to Item 11
q
q
q
q
If “No” to
all items, go
to Item 12
Explain what the changes in your work circumstances were, the dates they occurred, and why your condition
made these changes necessary.
CHANGES
When
Unable to
Work
Month
q Yes
CONDITION
Month
q Yes
q No
Day
Year
Go to Item 14b
Go to Section 4
Enter the date(s) of the work attempts.
Information About Your Medical Care
15 a
b
Enter an “X” in the appropriate box:
Have you received medical care or been examined
for your condition since the date in Item 8?
Enter an “X” in the appropriate box:
Are you scheduled for any additional medical care
u
for your condition(s) (i.e. Surgeries, etc.) after you file
this application?
Explain:
Form AA-17b (06-19)
Page 2
q Yes
q No
q Yes
q No
Explain below
Go to item 16
Treatment or 16
Testing
17
Enter an “X” in the appropriate box:
Have you been treated or tested (inpatient or outpatient) at a hospital,
institution or clinic, including a Department of Veterans Affairs or other
government facility?
q Yes
q No
Go to Item 17
Go to Item 18
Enter information about each hospital, institution, or clinic where you have received treatment or care
since the date in Item 8.
a
Name of Facility
Address of Facility (Street Address, City, State/Province
and Zip Code)
Attending Physician’s Name
Enter an “X” in the appropriate box:
Outpatient q
Inpatient q
Dates Treated or Tested
b
Telephone Number
Area Code
Patient Number
Describe Type of Treatment or Testing
Name of Facility
Address of Facility (Street Address, City, State/Province
and Zip Code)
Attending Physician’s Name
Enter an “X” in the appropriate box:
Outpatient q
Inpatient q
Dates Treated or Tested
Telephone Number
Area Code
Patient Number
Describe Type of Treatment or Testing
c Name of Facility
Address of Facility (Street Address, City, State/Province
and Zip Code)
Attending Physician’s Name
Enter an “X” in the appropriate box:
Outpatient q
Inpatient q
Area Code
Patient Number
Dates Treated or Tested
Doctor
Treatment
18
Telephone Number
Describe Type of Treatment or Testing
Enter an “X” in the appropriate box:
Has your personal physician or other doctor treated
you since the date in Item 8?
Page 3
q Yes
q No
Go to Item 19
Go to Item 20
Form AA-17b (06-19)
Doctor
Treatment
(Continued)
19 Enter information about each personal physician or other doctor who has treated you.
a
Name of Physician
Address of Facility (Street Address, City, State/Province
and Zip Code)
Dates Treated or Examined
b
Describe Type of Treatment or Testing
Name of Physician
Address of Facility (Street Address, City, State/Province
and Zip Code)
Area Code
Patient Number
Dates Treated or Examined
c
Telephone Number
Area Code
Patient Number
Telephone Number
Describe Type of Treatment or Testing
Name of Physician
Address of Facility (Street Address, City, State/Province
and Zip Code)
Area Code
Telephone Number
Patient Number
Dates Treated or Examined
Activity
Restriction
20
Describe Type of Treatment or Testing
Enter an “X” in the appropriate box:
Has a medical doctor restricted my daily
activities since the date in Item 8?
q Yes
q No
Go to Item 21
Go to Item 24
21 Enter the name of the medical doctor who imposed the restriction. Also enter the medical doctor’s
address if it has not been previously entered in items 17 or 19.
Name of Medical Doctor
Form AA-17b (06-19)
Address of Medical Doctor
(Street Address, City, State/Province and Zip Code)
Page 4
MONTH
YEAR
Activity
Restriction
(Continued)
22 Enter the date the restriction began.
23
List and describe the condition(s) and how your daily activities were restricted by the condition(s).
Medication
24
Enter an “X” in the appropriate box:
Are you currently taking prescribed medication(s).
25
Go to Item 25
Go to Section 5
Enter from the prescription labels the following infomation for all medications prescribed for you:
Name or type of medication, dosage, and frequency. (For example, Penicillin,1.5 gram tablet, 3 times a day).
NAME/TYPE:
Section 5
Schooling
q Yes
q No
DOSAGE:(grams, number of pills,etc.)
FREQUENCY:
Information About Your Education and Training
Enter the highest grade of school you completed.
26
27 a Enter an “X” in the appropriate box:
Are you currently attending school ( including online)?
q Yes
q No
Go to Item 27b
Go to Item 28
b Enter the date you began attending
c
to Present
Enter an “X” in the appropriate box:
Indicate what type of school you are
attending or enter the service you
receive. Use “Other” to indicate any
other type of school not listed.
q
q
q
q
q
Skip Item 28 and go to Item 29b.
28
Enter the date that you last attended school.
29 a Enter an “X” in the appropriate box:
Have you attended a technical school, or received
specialized/vocational training or service?.
Technical
Specialized
Vocational
Service:
Other:
Month
q Yes
q No
Day
Year
Go to Item 29b
Go to Item 30
b Describe the type of technical school you attended, or training or services you received and the
period of time you attended or received the training.
TYPE
30
31
32
From
To
Enter an “X” in the appropriate box:
Have or will you receive a degree, certificate, or
license for any training you received?
q Yes
q No
Go to Item 31
Enter an “X”in the appropriate box:
Is the degree, certificate, or license you received currently
valid?
Enter an “X”in the appropriate box:
Have you used any of the training in your work?
q Yes
q No
Go to Item 32
q Yes
q No
Go to Item 33
Page 5
Go to Section 6
Go to Section 6
Go to Section 6
Form AA-17b (06-19)
Section 6
Activities
33
Information About Your Daily Activities
Check the one box after each activity listed below that best describes your ability to do that activity.
•
EASY - I can easily do the activity.
•
DIFFICULT -I can do the activity with difficulty.
•
HARD - I can only do the activity with assistance.
•
NOT AT ALL - I cannot do the activity with assistance.
•
N.A. - Not applicable.
ACTIVITY
Easy
Difficult
Hard
Not At
All
N.A.
Sitting
q
q
q
q
q
Standing
q
q
q
q
q
Walking
q
q
q
q
q
Eating
q
q
q
q
q
Bathing
q
q
q
q
q
Dressing (Tying Shoes,
Combing Hair, Etc.)
q
q
q
q
q
Other Bodily Needs
q
q
q
q
q
Indoor Chores (Meal
Preparation, Laundry,
Cleaning, Etc.)
q
q
q
q
q
Outdoor Chores
(Shopping,Yardwork, Etc.)
q
q
q
q
q
Driving a Motor Vehicle
q
q
q
q
q
Using Public Transportation
q
q
q
q
q
Conducting Personal
Business (Talking to
and Dealing with Other
People)
q
q
q
q
q
Reading English (For
example, newspapers
and magazines)
q
q
q
q
q
Writing English (For
example, notes and
letters)
q
q
q
q
q
Form AA-17b (06-19)
Page 6
Explain each DIFFICULT,” “HARD,
and “NOT AT ALL” answer.
ACTIVITIES
(CONT.)
34
Describe your daily activities during a normal day (i.e., typical day from the time you get up until you go to
bed.)
35
a
b
Enter an “X”in the appropriate box:
Do you perform any volunteer work?
(Volunteer work is any work performed without pay)
d
36 a
b
d
Go to Item 36
Average Hours Per Week
Enter an “X”in the appropriate box:
Does your condition(s) restrict your ability to perform
volunteer work?
q Yes
q No
Go to Item 35d
q Yes
q No
Go to Item 36b
Go to Item 36
Describe the changes.
Enter an “X” in the appropriate box:
Do you participate in social or recreational activities?
For example, clubs, traveling, exercise, indoor/outdoor
sports, hobbies/crafts, ect.
Go to Section 7
Describe the social or recreational activities that you participate in, and enter the average number of
hours you participate per week.
Activity
c
Go to Item 35b
Describe the volunteer work you perform and reenter the number of average hours you participate
per week.
Volunteer Work
c
q Yes
q No
Average Hours Per Week
Enter an “X” in the appropriate box:
Does your condition(s) restrict your participation in the
activities listed above?
q Yes
q No
Go to Item 36d
Go to Section 7
Describe the changes.
Page 7
Form AA-17b (06-19)
Section 7
Work
Activitiies
Information About Your Work and Earnings
37 Enter an “X” in the appropriate box:
Have you ever been employed
or self-employed?
Go to Note and Item 38
q Yes
q No
Go to Section 8
Note: If you answered “Yes” and you are a widow(er) filing a disability
annuity also complete and return to the RRB Form G-251, Vocation Report
Work for an
Employer
38 Enter an “X” in the appropriate box:
Have you worked for pay for an employer in the last
12 months? (Do not include any self-employment.)
This
Calendar
Year
39 Enter your earnings, before any deduction, for each month you have already worked this year. Then, starting with
the current month, enter your expected gross earnings for this month and each remaining month this year.
Last
Calendar
Year
Go to Item 39
q Yes
q No
Go to Item 41
JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
40 Enter your earnings, before any deduction, for each month last year.
Self41
Employment
JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
q Yes
q No
Enter an “X” in the appropriate box:
Have you been self-employed in the last 12 months
Go to Note and Item 42
Go to Section 9
Note: If answered “Yes” also complete and return to the RRB
Form AA-4, Self Employment Questionnaire
This
Calendar
Year
This
Calendar
Year
Work
Next 12
Months
42 Enter your net earnings for each month you have already worked this year. Then, starting with the current month,
enter your expected earnings for this month and each remaining month this year.
JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
43 Enter your net earnings, before any deduction, for each month this year.
44
JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
Enter an “X” in the appropriate box:
Do you expect to work during the next 12 months?
(Include self-employment, if any.)
Form AA-17b (06-19)
Page 8
q Yes
q No
Go to Item 45
Go to Section 8
Work Next
12 Months
Cont.
45
Enter the name and address of the person or
company for whom you expect to work. (if Selfemployed, enter “Self.”)
46
Enter the date(s) you expect to work. (For example,
June and July, “Indefinitely Starting 9-2020,” etc.)
47
Enter the gross amount you expect
to earn. (If you are self-employed,
enter the net amount)
Section 8
Filing AA-17
or AA-18
48
Social
Security
Benefits
49
50
Public
Service
Pension
51
General Information
Enter an “X” in the appropriate box:
Are you filing either Form AA-17 or Form AA-18
at this time?
q Yes
q No
Go to Item 54
Enter an “X” in the appropriate box:
Have you filed, or expect to file, for monthly
social security disability benefits?
q Yes
q No
Go to Item 50
q Yes
q No
Go to Item 52
q Yes
q No
Go to Note and Item 54
Go to Item 49
Go to Item 51
Enter the social security claim number
under which you have filed or will file.
Enter an”X” in the appropriate.
Are you receiving or do you expect to receive a pension or have
you received or do you expect to receive a lump-sum payment
instead of a pension based on your earnings from an agency of
the Federal, state, or local government? (Answer “NO” if your
only government pension payments are social security, railroad
retirement, veterans affairs, worker’s compensation , or black
lung benefits. Also answer “NO” if you received a lump-sum
payment that was just your contributions to the pension fund
plus interest.
52 Are you or were you an employee of the Federal Government?.
Go to Item 54
Go to Item 53
Note:If you answer “Yes,” also complete and return the RRB Form G-208,
Public Service Pension Questionnaire, and verification of your pension.
53 Enter an “X” in the box:
On your last day of employment, were you employed by a state or
local government or the military service and social security (FICA)
taxes were being deducted from your public service earnings?
q Yes
q No
Go to Item 54
Go to Note and Item 54
Note:If you answer “No,” also complete and return the RRB Form G-208,
Public Service Pension Questionnaire, and verification of your pension.
Criminal
Offense
54 Enter an “X” in the box:
Within the past 12 months were you imprisoned or given a
sentence of confinement due to a conviction for a criminal
offense?
55 Enter the date of the conviction.
56 Enter the date of the conviction.
Is your disability related to the commission of the criminal
offense?
Form AA-17b (06-19)
Page 9
q Yes
q No
Go to Item 55
Go to Section 9
Month
Day
q Yes
q No
Year
Criminal
Offense
Cont.
57
Enter the date of the sentence of confinement.
Month
Day
Year
58
Enter the date that confinement began.
Month
Day
Year
59
Enter an “X” in the appropriate box:
is your disability related to your confinement?
60
Enter an “X” in the appropriate box:
Has the confinement ended?
61
Section 9
Remarks
q Yes
q No
q Yes
q No
Go to Item 61
Go to Section 9
Month
Enter the date confinement ended.
Remarks
Day
Year
62 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 space to enter
any additional information that you feel may be important to include.
Form AA-17b (06-19)
Page 10
Section 10
Certification
63
64
Certification
a
Did you complete this application with the assistance of
an attorney or non-family member (RRB staff excluded)?
b
Enter the name and address of the attorney or nonfamily member who assisted with completing this
application.
c
Did you pay a fee to the attorney or non-family
member who assisted with completing this application?
q Yes
q No
Go to Item 63b
Go to Item 64
q Yes
q No
Enter an “X” in the appropriate box:
Will you have a guardian or other representative sign this
application on your behalf?
q Yes
q No
Go to Item 65
Go to Item 65
Note: If answered “Yes,” the guardian or other representative of the applicant must sign this application. That person must also complete and return Form AA-5, Application for Substitution of Payee.
65
I Certify that the information I gave the Railroad Retiement Board (RRB) on this application is true to the best
of my knowledge. I know that if I make a false statement or withhold information in order to receive benefits
from the RRB, I am committing a crime under Federal law which may be punishable by fines, imprisonment, or
both. I have recevied and reviewed the booklet, RB-17b, Widow(er)’s Disability Benefits. I understand that I
am responsible for reporting events that would affect my annuity as explained in the booklet.
I agree to immediately notify the RRB:
• If I work for any employer, railroad or nonrailroad, or perform any self-employment work;
• If my condition improves;
• If I am confined in a jail, or prison, penal institution, or correctional facility due to a conviction for a
criminal offense;
• If my address changes;
• If I remarry;
• If I file for social sercurity benefits based on any person’s earnings record;
• If I begin to receive a pension from an agency of the Federal, state. or local government of if my
present payment changes
I know that if I am receiving a disability annuity and fail to report work and earnings promptly, I am
committing a crime pinishable by Federal law that may result in criminal prosecution and/or penalty
deductions in my annuity payments.
Signature
(First Name, Middle Initial,
Last Name)
Month
Day
Year
Date
66
If this certification is signed by mark (X) in Item 65, two witnesses who know the person signing must sign
below, giving their full address and daytime telephone number.
a. Signature of witness
b. Signature of witness
Address (Number and Street)
Address (Number and Street)
City, State/Province, and Zip Code
City, State/Province, and Zip Code
Daytime Telephone Number (include area code)
Daytime Telephone Number (include area code)
(
)
(
Page 11
)
Form AA-17b (06-19)
Section 11
How To Return Your Application
Before you return your application, check to make sure that:
X
Every question that applies to you has been answered.
X
You have entered “unknown” in any answer space for which you were unable to answer a question.
X
You have signed and dated the application.
X
You have included all the needed proofs listed in the letter you received with this application.
When you received 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 office shown on page 13 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:
X
NEEDED PROOFS
X
THE APPLICATION FORM ITSELF
X
ADDITIONAL FORMS YOU WERE ASKED TO COMPLETE
Note: Make no entries on page 13, which is the receipt for your claim. After the RRB receives your application,
they will complete the blanks on the receipt and send it back to you. When it is returned to you, 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 the receipt within two weeks after you filed this application, please contact us so
we can find out what is causing the delay.
Important Notices
PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICES
The information asked for in this form is needed to determine your entitlement to benefits under the Railroad
Retirement Act. The RRB’s authority for requesting this information is Section 7(b)(6) of the Railroad Retirement Act.
We estimate that this form takes an average of 40 to 50 minutes per response to complete, including the time for
reviewing the instructions, getting the needed data, and reviewing the completed form. Federal agencies may not
conduct or sponsor, and respondents are not required to respond to, a collection of information unless it displays
a valid OMB number. If you wish, send comments regarding the accuracy of our estimate or any other aspect of
this form, including suggestions for reducing the completion time, to: the Associate Chief Information Officer for
Policy and Compliance, Railroad Retirement Board, 844 North Rush Street, Chicago, IL 60611-1275.
COMPUTER MATCHING AND PRIVACY PROTECTION ACT NOTICE
The Computer Matching and Privacy Protection Act of 1988 requires the RRB to advise you that information you
have provided may be used, without your consent, in automated matching programs. These matching programs are
a computer comparison of RRB records with records kept by other Federal, state, or local governmental agencies.
Information from these matching programs can be used to establish or verify a person’s eligibility for federally funded
or administered benefit programs and for repayment of payments or delinquent debts under these programs.
Page 12
Form AA-17b (06-19)
Receipt For Your Claim
EMPLOYEE’S NAME
APPLICANT’S NAME
RAILROAD RETIREMENT BOARD CLAIM NUMBER
DATE CLAIM RECEIVED
Your application for railroad retirement disability benefits has been received and will be processed as quickly as possible.
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. The changes to be reported are listed below. Always give us your claim number when writing or calling
about your claim. If you have any questions about your claim we will be glad to help you. If you need to personally visit one
of our field offices, please call for an appointment. You will not be refused service if you do not have an appointment, but
our staff can serve you better when an appointment is made. Most offices are open to the public from 9:00 a.m. to 3:30
p.m., Monday, Tuesday, Thursday. and Friday and from 9:00 a.m. to 12:00 p.m. on Wednesday.
Always Report These Changes To The RRB
l
l
l
l
l
l
Address — If your address changes.
Work — If I perform work for any employer, railroad or nonrailroad, or perform any self-employment work.
Remarriage — If you remarry.
Condition — If your condition improves.
Social Security — If you file for benefits on any person’s earnings.
Criminal Offense — If you are confined in a jail, prison, penal institution, or correctional facility due to a conviction
for a criminal offense.
l Public Service Pension — If you begin to receive a pension from an agency of the Federal, state, or local
government or if your present payments change.
How To Report Changes
When a change occurs after you are entitled to disability benefits, you should report the change at once. You or your
representative can make the reports by telephone, mail, or in person, whichever you prefer.
To report any of the above changes, contact:
u
Telephone Number:
(
If for some reason you cannot contact that office, you should contact:
u
Form AA-17b (06-19)
U S RAILROAD RETIREMENT BOARD
844 N RUSH ST
CHICAGO IL 60611-1275
Page 13
| File Type | application/pdf |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |