AA-17sum (01-19) ( Application Summary

United States of America
Railroad Retirement Board

CURRENT (ALL POSSIBLE)

Form Approved
OMB 3220-0030

APPLICATION SUMMARY FOR (A WIDOW(ER)'S ANNUITY/
A DISABLED WIDOW(ER)'S ANNUITY/A YOUNG MOTHER'S/FATHER’S ANNUITY/A
CHILD'S ANNUITY/A DISABLED CHILD'S ANNUITY/A FULL-TIME STUDENT'S ANNUITY/A
PARENT'S ANNUITY/MEDICARE/A MEDICARE SPECIAL ENROLLMENT PERIOD)

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's/Father’s Annuity/a
Child’s Annuity/a Disabled Child’s Annuity/a Full-Time Student’s Annuity/a Parent’s Annuity/
Medicare/a Medicare Special Enrollment Period) under the Railroad Retirement Act. Review the
information for accuracy. If there are any errors, notify the Railroad Retirement Board (RRB)
immediately, and no later than 10 days from the date you receive this summary.
This information is certified by you to be true and correct to the best of your knowledge. You have
been informed and you acknowledge that making a false or fraudulent statement or withholding
information, in order to receive benefits from the RRB, is a crime under Federal law which may be
punishable by fines, imprisonment, or both.
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)

RRB Form AA-17sum (01-19)

from 99/99/9999 to 99/99/9999
from 99/99/9999 to 99/99/9999
from 99/99/9999 to 99/99/9999
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United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0030

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.

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
2
3

Was alive on October 1, 1981 and had at least 25 years of railroad service, and
“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
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
RRB Form AA-17sum (01-19)

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United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0030

18 The employee was survived by a parent who may be entitled to monthly benefits.
Name
Relationship
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's/Father’s Annuity/Child’s Annuity/Disabled Child’s
Annuity/Full-Time Student’s Annuity/Parent’s Annuity/
Medicare/Medicare Special Enrollment Period)

Application Filing Date
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.
RRB Form AA-17sum (01-19)

32948 64790 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0030

Applicant’s Marriages
26 You were married to someone other than the employee.
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 have filed or plan to file in the next three months for Social Security benefits on your own
account.
39 You have filed or plan to file in the next three months for Social Security benefits on the account
of:
Name
Social Security Number
40 You have not filed nor do you plan to file in the next three months for Social Security benefits on
any account number
RRB Form AA-17sum (01-19)

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United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0030

41 You have not filed nor do you plan to file in the next three months for Social Security benefits on
an additional account number.
42 You are currently receiving a Social Security benefit.
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 do you 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 total earnings were less than (annual exempt amount).
55 In (last year), you earned more than (monthly exempt amount) in each month.
RRB Form AA-17sum (01-19)

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United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0030

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).
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.
RRB Form AA-17sum (01-19)

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United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0030

69 You have selected mm/dd/yyyy for the beginning date of your annuity.
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.
(Printed if application type is widow(er), child or parent who is FRA or older.)
Your application for a (ENTER TYPE OF BENEFIT) has been released and will be processed as
quickly as possible. If you do not receive notification about your application by (ENTER DAYS
FROM FILING DATE BASED ON CUST SER PLAN) you should contact the field office shown
below.
You have received and reviewed the booklets RB-17, Survivor Annuities, and RB-9s, Events that
Affect a Survivor Annuity. It is your responsibility to report events that would affect your annuity as
explained in the booklets. Failure to report any of the events listed below or other events that may
affect your annuity may result in criminal and/or civil prosecution.
(Printed if application type is widow(er), child or parent who is under FRA.)
Your application for a (ENTER TYPE OF BENEFIT) has been released and will be processed as
quickly as possible. If you do not receive notification about your application by (ENTER DAYS
FROM FILING DATE BASED ON CUST SER PLAN) you should contact the field office shown
below.
You 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. It is your
responsibility to report events that would affect your annuity as explained in the booklets and form.
Failure to report any of the events listed below or other events that may affect your annuity may
result in criminal and/or civil prosecution.
RRB Form AA-17sum (01-19)

32948 64790 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0030

(Printed if application type is disabled widow(er).)
Your application for a Disabled Widow(er)’s annuity has been released and will be processed as
quickly as possible. If you do not receive notification about your application by (ENTER DAYS
FROM FILING DATE BASED ON CUST SER PLAN) you should contact the field office shown
below.
You 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. It is your responsibility to report
events that would affect your annuity as explained in the booklets. Failure to report any of the events
listed below or other events that may affect your annuity may result in criminal and/or civil
prosecution.
(Printed if application type is disabled child.)
Your application for a Disabled Child’s annuity has been released and will be processed as quickly
as possible. If you do not receive notification about your application by (ENTER DAYS FROM
FILING DATE BASED ON CUST SER PLAN) you should contact the field office shown below.
You have received and reviewed the booklets RB-17, Survivor Annuities, RB-19a, Child Disability
Benefits, and RB-9s, Events that Affect a Survivor Annuity. It is your responsibility to report events
that would affect your annuity as explained in the booklets. Failure to report any of the events listed
below or other events that may affect your annuity may result in criminal and/or civil prosecution.
If you change your address, or if there is some other change that may affect your application, you or
your representative should report the change at once. 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.
Always Report These Changes to the RRB
 Death – If the child dies. (Printed if application type is 5, 6 or 7.)
 Marriage – If you remarry. (Printed if application type is 2, 3, 4, 9.)
 Marriage – If you marry. (Printed if application type is 5, 6 or 7.)
 Social Security – If you file for social security benefits based on any person’s earnings record.
 Social Security – If benefits you receive directly from the Social Security Administration are
adjusted for a reason other than normal cost-of-living increases.
 Public Pension – If you begin to receive a pension or receive a lump-sum payment based on
your earnings at an agency of the Federal, state or local government. (Printed if application type
is 2, 3 or 4.)
 Public Pension – If the amount of your pension based on your earnings from a Federal, state or
local government agency changes. (Printed if application type is 2, 3 or 4.)
 Earnings – If your earnings change. On your application you told us you expect your total
earnings for _____ to be $ ________. (Applicant is less than full retirement age.)
RRB Form AA-17sum (01-19)

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United States of America
Railroad Retirement Board

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Form Approved
OMB 3220-0030

 On your application you told us you expect your total earnings for _____ to be less than $
________. (Applicant is less than full retirement age.)
 You are earning more than $ ______ a month. (Applicant is less than full retirement age.)
 You are not earning more than $ _____ a month. (Applicant is less than full retirement age.)
Railroad Work – If you go to work for a railroad or railroad labor organization or work in any
capacity in the railroad industry.
Address – If your address changes. (Printed only on Medicare Applications.)
Address – If your address changes, even if your payments are sent to a financial organization.
Bank Account – If your financial organization or the account number at your financial
organization changes.
Applicant is in Your Care – If any person for whom you are receiving an annuity dies or leaves
your care.
Criminal Offense – If you are confined in a jail, prison, penal institution or correctional facility due
to a conviction for a criminal offense.
School Attendance – If you stop attending school full-time. (Printed if Application Type is 7.)
Death or Disability – Your representative should notify the RRB immediately if you die or
become unable to handle your own benefits.

How to Report Changes
When a change occurs after you have begun receiving your annuity, you should report the change at
once. You or your representative can make the reports by telephone, mail or in person, whichever
you prefer.
(Paragraph will be printed if non-disability applicant is less than full retirement age.)
In most cases, we calculate how much to reduce your annuity because of your earnings based on
either the earnings estimate you gave us when you applied for benefits, or on reports submitted by
employers to the Social Security Administration. As a reminder, you should report your earnings
(1) when we ask for a report of your earnings or (2) if any of the following happens:
 You stop working;
 You start working and expect to earn more than the annual exempt amount;
 Your employment is not covered under the Social Security Act (i.e., FICA taxes are not
deducted from your pay);
 You work for a railroad or railroad labor organization; or
 You return to work for your last pre-retirement nonrailroad employer.
To report any changes or ask questions, you should contact:
(Field Office Address and Toll-Free Telephone Number)

RRB Form AA-17sum (01-19)

32948 64790 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0030

If for some reason you are unable to contact that office, you should contact:
U.S. Railroad Retirement Board
844 N Rush Street
Chicago, Illinois 60611-1275
http://www.rrb.gov

RRB Form AA-17sum (01-19)

32948 64790 22000 06051 32704

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