AA-17cert (09-15)( Application Summary and Certification

United States of America
Railroad Retirement Board

CURRENT (ALL POSSIBLE)

Form Approved
OMB 3220-0030

APPLICATION SUMMARY and CERTIFICATION
Employee’s Name
RR Claim No.
The following information was either supplied by or verified by you in support of your
application for (a Widow(er)’s Annuity/a Disabled Widow(er)’s Annuity/a Young
Mother/Father’s Annuity/a Child’s Annuity/a Disabled Child’s Annuity/a Full-Time
Student’s Annuity/a Parent’s Annuity/a Medicare/Medicare Special Enrollment Period)
under the Railroad Retirement Act. After you have reviewed the information, make any
changes on the summary, initial the change and sign the certification on the last page.
Return the certification and all pages of the summary to the RRB.
Employee Information
Social Security Number
Date of Birth
Date of Death
Military Service
1

The employee was not in active military service after September 7, 1939.

2

The employee had military service after September 7, 1939.

Recent Employment
3

The employee had not worked in the two years before death.

4

The employee worked for the following companies in the last two years:
(Company Name)
(Company Name)
(Company Name)

from 99/99/9999 to 99/99/9999
from 99/99/9999 to 99/99/9999
from 99/99/9999 to 99/99/9999

5

The employee did not have self-employment earnings in any of the last three years.

6

The employee’s net earnings from self-employment were less than $400 in each of
the last three years.

7

The employee’s net earnings from self-employment were $400 or more in one of the
last three years.

RRB Form AA-17cert (09-15)

92948 74890 22000 06051 32704

Page 1

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0030

Railroad Employment
8

The employee had a current connection with the railroad industry.

9

A current connection with the railroad industry is “deemed” because the employee:
1 Was alive on October 1, 1981 and had at least 25 years of railroad service, and
2 “Involuntarily and without fault” stopped working for the railroad on or after
October 1, 1975 and was never called back to work for the railroad employer, and
3 Did not decline an offer from a railroad employer to return to a job in the same
“class or craft” as the last railroad job.

10 The employee does not have a current connection with the railroad industry.
Employee’s Family
11 The employee was not survived by a widow(er) or surviving divorced spouse who may
be entitled to monthly benefits.
12 The employee was not survived by a child who may be entitled to monthly benefits.
13 The employee was not survived by a grandchild who may be entitled to monthly
benefits.
14 The employee was not survived by a parent who may be entitled to monthly benefits.
15 The employee was survived by a widow(er) or surviving divorced spouse who may be
entitled to monthly benefits.
Name
Relationship
16 The employee was survived by a child who may be entitled to monthly benefits.
Name
Relationship
17 The employee was survived by a grandchild who may be entitled to monthly benefits.
Name
Relationship
18 The employee was survived by a parent who may be entitled to monthly benefits.
Name
Relationship

RRB Form AA-17cert (09-15)

92948 74890 22000 06051 32704

Page 2

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0030

Applicant Information
Name and Address
Daytime Telephone Number
Social Security Number
Date of Birth

Type of Application Filed

(Widow(er)’s
Annuity/Disabled
Widow(er)’s
Annuity/Young
Mother/Father’s
Annuity/Child’s
Annuity/Disabled Child’s Annuity/Full-Time Student’s
Annuity/Parent’s Annuity/ Medicare/Medicare Special
Enrollment Period)

19 You applied for this benefit based on your relationship to the employee.
20 You applied for this benefit based on your relationship to the employee and that you
are disabled.
21 You applied for this benefit based on your relationship to the employee and that you
have the following child(ren) in your care.
Name

SS Number

DOB

Filing For

22 You applied for this benefit based on your relationship to the employee and that you
are a full-time student.
23 You have requested that any payment due you be sent to the following bank account:
Bank Name
Routing Number
Account Number
Account Type
24 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.
25 Any payment due you will be sent to the address shown above.
Applicant’s Marriages
26 You were married to someone other than the employee.
RRB Form AA-17cert (09-15)

92948 74890 22000 06051 32704

Page 3

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0030

27 You were not married to anyone other than the employee.
28 You have married since the employee’s death.
29 You have remarried since your divorce from the employee.
30 You have not remarried since your divorce from the employee.
31 You have never been married.
32 You were married and that marriage ended on mm/dd/yyyy.
33 You are currently married.
34 You have remarried since the employee’s death.
35 You have not remarried since the employee’s death.
Criminal Offense Information
36 Within the past 12 months you have not been imprisoned or been given a sentence of
confinement due to a conviction for a criminal offense.
37 Within the past 12 months you have been imprisoned or been given a sentence of
confinement due to a conviction for a criminal offense.
Other Government Benefits
38 You are currently receiving a Social Security benefit.
39 You have filed or plan to file in the next three months for Social Security benefits on
your own account.
40 You have filed or plan to file in the next three months for Social Security benefits on
the account of:
Name
Social Security Number
41 You have not filed nor plan to file in the next three months for Social Security benefits
on any account number.
42 You have not filed nor plan to file in the next three months for Social Security benefits
on an additional account number.
RRB Form AA-17cert (09-15)

92948 74890 22000 06051 32704

Page 4

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0030

43 You are not receiving a Social Security benefit.
44 In the past month you have filed or plan to file in the next three months for Railroad
Retirement benefits based on your own earnings.
45 In the past month you have filed or plan to file in the next three months for Railroad
Retirement benefits based on the account of:
Name
Social Security Number
46 In the past month you have not filed nor plan to file in the next three months for
Railroad Retirement benefits on any account number.
47 You are currently receiving a Railroad Retirement annuity.
48 You are not receiving a Railroad Retirement annuity.
49 You are receiving a pension based on your earnings from a Federal, state or local
government agency.
50 You received a lump-sum payment instead of a monthly pension from a Federal, state
or local government agency.
51 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.
52 You expect to receive a pension or lump-sum payment based on your earnings from a
Federal, state or local government agency.
Earnings Information
53 In (last year), your total earnings were (actual earnings amount).
54 In (last year), your earnings were less than (annual exempt amount).
55 In (last year), you earned more than (monthly exempt amount) in each month.
56 In (last year), you earned less than (monthly exempt amount) in the following months:
January February March April May June July August September October
November December
57 In (current year), you expect your total earnings will be (estimated earnings).
RRB Form AA-17cert (09-15)

92948 74890 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0030

58 In (current year), you expect your total earnings will be less than (annual exempt
amount).
59 In (current year), you expect to earn more than (monthly exempt amount) in each
month.
60 In (current year), you expect to earn less than (monthly exempt amount) in the
following months:
January February March April May June July August September October
November December
61 In (next year), you expect your total earnings will be (estimated earnings).
62 In (next year), you expect your total earnings will be less than (annual exempt
amount).
Railroad Work
63 You worked for a railroad, railroad labor organization or other employer in the railroad
industry.
64 Your date last worked for a railroad, railroad labor organization or other employer in
the railroad industry was mm/dd/yyyy.
65 This year, you worked for a railroad, railroad labor organization or other employer in
the railroad industry in the following months:
January February March April May June July August September October
November December
66 Last year, you worked for a railroad, railroad labor organization or other employer in
the railroad industry in the following months.
January February March April May June July August September October
November December
67 You have not worked for a railroad, railroad labor organization or other employer in
the railroad industry.
Beginning Dates and Filing Dates
68 You have requested your annuity begin on the earliest date permitted by law, even if
you will receive a reduced annuity.
69 You have selected mm/dd/yyyy for the beginning date of your annuity.
RRB Form AA-17cert (09-15)

92948 74890 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0030

70 This application will protect your filing date for Social Security benefits.
71 You do not want this application to protect your filing date for Social Security benefits.
Medicare
72 You are enrolled in the Medicare Medical Insurance Plan (Part B).
73 You wish to enroll in the Medicare Medical Insurance Plan (Part B).
74 You do not wish to enroll in the Medicare Medical Insurance Plan (Part B) at this time.
75 You are claiming a special enrollment period based on coverage by an employer
group health plan.
76 You are claiming premium surcharge relief based on coverage by an employer group
health plan.
Application for (a Widow(er)’s Annuity/a Disabled Widow(er)’s Annuity/a Young
Mother/Father’s Annuity/a Child’s Annuity/Disabled Child’s Annuity/a Full-Time Student’s
Annuity/a Parent’s Annuity/Medicare/a Medicare Special Enrollment Period) Certification
Employee’s RR Claim Number
Employee’s Name
Employee’s Social Security Number
Applicant’s Name
Applicant’s Social Security Number
I certify that the information I have given to the Railroad Retirement Board (RRB) in
relation to this application is true to the best of my knowledge. I know that if I make a
false or fraudulent 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 received and reviewed a summary of the information I provided. I understand that I
have an obligation to advise the RRB immediately if there are any errors in the summary I
received, and I have made and initialed any corrections on the summary being returned to
the RRB.

RRB Form AA-17cert (09-15)

92948 74890 22000 06051 32704

Page 7

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0030

(Printed if application type is widow(er), child or parent who are FRA or older.)
I have received and reviewed the booklets RB-17, Survivor Annuities, and RB-9s, Events
that Affect a Survivor Annuity. I understand that I am responsible for reporting events that
would affect my annuity as explained in the booklets. Failure to report any of the events
listed below or other events that may affect my annuity may result in criminal and/or civil
prosecution.
(Printed if application type is widow(er), child or parent who are under FRA.)
I have received and reviewed the booklets RB-17, Survivor Annuities, RB-9s, Events that
Affect a Survivor Annuity, and Form G-77, How Earnings Affect Payment of Survivor
Annuities. I understand that I am responsible for reporting events that would affect my
annuity as explained in the booklets and form. Failure to report any of the events listed
below or other events that may affect my annuity may result in criminal and/or civil
prosecution.
(Printed if application type is disabled widow(er).)
I have received and reviewed the booklets RB-17, Survivor Annuities, RB-17b,
Widow(er)’s Disability Benefits, and RB-9s, Events that Affect a Survivor Annuity. I
understand that I am responsible for reporting events that would affect my annuity as
explained in the booklets. Failure to report any of the events listed below or other events
that may affect my annuity may result in criminal and/or civil prosecution.
(Printed if application type is disabled child.)
I have received and reviewed the booklets RB-17, Survivor Annuities, RB-19a, Child
Disability Benefits, and RB-9s, Events that Affect a Survivor Annuity. I understand that I
am responsible for reporting events that would affect my annuity as explained in the
booklets. Failure to report any of the events listed below or other events that may affect
my annuity may result in criminal and/or civil prosecution.
I agree to immediately notify the RRB, if
 I remarry.
 I marry.
 I begin to receive a pension or receive a lump-sum payment based on my earnings at
a Federal, state or local government agency.
 The amount of my pension based on my earnings from a Federal, state or local
government agency changes.
 I file for social security benefits on any person’s earnings record.
 If benefits I receive directly from the Social Security Administration are adjusted for a
reason other than normal cost-of-living increases.
 I go to work for a railroad or railroad labor organization or work in any capacity in the
railroad industry.
 My expected earnings amount changes.
RRB Form AA-17cert (09-15)

92948 74890 22000 06051 32704

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United States of America
Railroad Retirement Board


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Form Approved
OMB 3220-0030

My address changes.
My financial organization or the account number at my financial organization changes.
Any person for whom I am receiving benefits dies or leaves my care.
I am confined in a jail, prison, penal institution or correctional facility due to a
conviction for a criminal offense.

_________________________________
Signature (First Name, Middle Initial, Last Name)

___________________
Date (Month/Day/Year)

If this certification is signed by mark (“X”), two witnesses who know the person signing must sign below, giving
their full addresses and daytime telephone numbers.

__________________________________
Signature of Witness

_______________________________
Signature of Witness

__________________________________
Address (Street, City, State and ZIP Code)

_______________________________
Address(Street, City, State and ZIP Code)

(_____)____________________________
Daytime Telephone Number

(_____)________________________
Daytime Telephone Number

RRB Form AA-17cert (09-15)

92948 74890 22000 06051 32704

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