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

United States of America
Railroad Retirement Board

CURRENT (COMPLETED)

Form Approved
OMB 3220-0030

APPLICATION SUMMARY and CERTIFICATION
Employee’s Name
RR Claim No.

Jane Public
A 123-45-6789

The following information was either supplied by or verified by you in support of your
application for a Widow(er)’s Annuity 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

123-45-6789
01/02/1940
08/02/2005

Military Service
The employee was not in active military service after September 7, 1939.
Recent Employment
The employee worked for the following companies in the last two years:
Star Stainless

from 05/20/2010 to 08/01/2012

The employee did not have self-employment earnings in any of the last three years.
Railroad Employment
The employee had a current connection with the railroad industry.
Employee’s Family
The employee was not survived by a child who may be entitled to monthly benefits.
The employee was not survived by a grandchild who may be entitled to monthly benefits.
The employee was survived by a widow(er) or surviving divorced spouse who may be
entitled to monthly benefits.
John Public
Widow(er)
The employee was survived by a parent who may be entitled to monthly benefits.
Michael Michaels
Father

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

Applicant Information

Daytime Telephone Number
Social Security Number
Date of Birth

John Public
844 N Rush St
Chicago, Il 60611
312-555-1212
987-65-4321
06/06/1946

Type of Application Filed

Widow(er)’s Annuity

Name and Address

You applied for this benefit based on your relationship to the employee.
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.
Applicant’s Marriages
You were not married to anyone other than the employee.
You have not remarried since the employee’s death.
Criminal Offense Information
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.
Other Government Benefits
You have filed or plan to file in the next three months for social security benefits on your
own account.
You are not receiving a social security benefit.
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.
You are not receiving a railroad retirement annuity.
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.
Earnings Information
In 2011, your total earnings were less than $14,160.00
In 2012, you expect your total earnings will be $25,720.00
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

Railroad Work
You have not worked for a railroad, railroad labor organization or other employer in the
railroad industry.
Beginning Dates and Filing Dates
You have requested your annuity begin on the earliest date permitted by law, even if you
will receive a reduced annuity.
This application will protect your filing date for social security benefits.
Application for a Widow(er)’s Annuity - Certification
Employee’s RR Claim Number
Employee’s Name
Employee’s Social Security Number

A 123-45-6789
Jane Public
123-45-6789

Applicant’s Name
Applicant’s Social Security Number

John Public
987-65-4321

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.
I have received and reviewed the booklets RB-17, Survivor Annuities, and 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.

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

I agree to immediately notify the RRB, if
 I remarry.
 I begin to receive a pension or receive a lump-sum payment based on my earnings
from a Federal, state or local government agency.
 I file for social security benefits on any person’s account.
 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.
 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

Page 4