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

United States of America
Railroad Retirement Board

CURRENT (COMPLETED)

Form Approved
OMB 3220-0030

APPLICATION SUMMARY FOR A WIDOW(ER)’S ANNUITY
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. 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
and may be punishable by fines, imprisonment or both.
Employee Information
Social Security Number
Date of Birth
Date of Death

123-45-6789
01/02/1940
08/02/2012

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 05/20/1997 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.
RRB Form AA-17sum (01-19)

92948 74890 22000 0605132704

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United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0030

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

Applicant Information
Name and Address

Daytime Telephone Number
Social Security Number
Date of Birth

John Public
844 N Rush Street
Chicago IL 60611
555-555-1212
987-65-4321
06/06/1945

Type of Application Filed
Application Filing Date

Widow(er)’s Annuity
09/17/2018

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

92948 74890 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0030

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.
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 2017, your total earnings were less than $14,460.00.
In 2018, you expect your total earnings will be $25,720.00.
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.
Medicare
You are enrolled in the Medicare Medical Insurance Plan (Part B).
Your application for a 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 December 2, 2018 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)

92948 74890 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0030

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
 Marriage – If you remarry.
 Social Security – If you file for social security benefits based on any person’s earnings
record.
 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.
 Earnings – If your earnings change. On your application you told us you expect your
total earnings for 2018 to be $45,720.
 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, 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.
 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.
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;

RRB Form AA-17sum (01-19)

92948 74890 22000 06051 32704

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United States of America
Railroad Retirement Board





Form Approved
OMB 3220-0030

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:
U.S. Railroad Retirement Board
Hale Boggs Federal Bldg
Suite 1045
500 Poydras Street
New Orleans LA 70130-3399
877-772-5772
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)

92948 74890 22000 06051 32704

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