RL-94F (XX-XX) Survivor Questionnaire

Survivor Questionnaire

Form RL-94F (XX-XX) - PROPOSED

OMB: 3220-0032

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PROPOSED




United States of America

Railroad Retirement Board

BIS - Policy & Compliance

844 North Rush Street

Chicago, IL 60611-1275

WWW.RRB.GOV


Toll-Free Number: 1-877-772-5772


Office Hours: M-T-TH-F 9:00 AM to 3:30 PM

Weds. 9:00 AM to 12:00 PM - Closed Federal Holidays




     

     

     

     

 



     

     

     

     

     



In reply refer to

Name of Deceased Railroad Employee

     

Name of Deceased Annuitant

     









To assist us in determining whether there are any benefits payable under the Railroad Retirement Act due to the death of the person named above, please complete the enclosed questionnaire and return it using the enclosed envelope. If you do not know the answer to an item, write "Unknown" in that item.

If the person was receiving an annuity under the Railroad Retirement Act, the annuity is not payable for the month in which the annuitant died. Annuity checks are dated the first of the month and cover payment for the previous month. If you receive a check(s) for any month(s) for which the person should not be paid, you should return it to the:

Department of the Treasury RRB field office

Philadelphia Financial Center or at address shown above

P.O. Box 513198

Philadelphia, PA 19115-63198


If the person was enrolled in Direct Deposit, notify the financial institution to return all payments that are received after the date of death.

This is not an application for benefits. If benefits are payable, the eligible person(s) will be required to file an application.

Special Instructions

If there is an "X" in this box, complete only Sections 4 and 6.

Sincerely,



     

     

     


Enclosure      

     





United States of America Form Approved

Railroad Retirement Board OMB No. 3220-0032

Survivor Questionnaire

Section 7(b) of the Railroad Retirement Act (RRA) of 1974 authorizes the U.S. Railroad Retirement Board to gather information and records needed to assure proper administration of the RRA. The information obtained from this questionnaire will be used for determining whether benefits are payable under the RRA. Although you are not required to furnish this information which is necessary to determine eligibility for benefits, if you fail to do so, nonpayment of benefits may result.

We estimate this form takes an average of 10 minutes per response to complete, including the time needed 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 completion time, to Associate Chief Information Officer for Policy and Compliance, Railroad Retirement Board, 844 North Rush Street, Chicago, Illinois 60611-1275.

Instructions


Type or print legibly in ink. If you need more space than is provided to answer a question, continue in Section 5. If you do not know the answer to a question, print "Unknown" in the space provided for the answer.

Some items on this questionnaire 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. Follow the instructions that tell you to "Go to" another item. These are designed to save you time and help you move through the questionnaire quickly. If no "Go to" instructions are given, answer the next item in order. Do not skip any items unless directed to do so.

Section 1

Identifying Information

Check the information entered by the Railroad Retirement Board (RRB) for Items 1 through 4 for accuracy.

 If the information is correct, go to Section 2.

If the information is not correct, cross out the incorrect information and enter the correct information above it.

If the information is missing, fill it in.

1

Deceased Employee's Name

2 Place of Death (City and State)

     

3

Date of Birth

     

4 Date of Death

     

Section 2

Information About Employee's Work Services and Family

5

If the employee was ever in active military service enter the dates of service, otherwise go to Item 6.

From

To

Month

Day

Year

Month

Day

Year







6

Furnish the following information regarding the employee's employment after stopping work in the railroad industry. (Include any part-time work. If the employee worked for him/herself, write "self-employed" in the first column.)

Name and Mailing Address of Employer

Began

Ended

Month

Year

Month

Year
















7

Was the employee survived by a widow(er) or a remarried widow(er)?

(Check one)

Yes - Complete a-e, below

No - Go to Item 8


a

Widow(er)'s Name, Mailing Address, and Telephone Number

Name _________________________________________________________________________________

Address _________________________________________________________________________________

_________________________________________________________________________________

Telephone Number (Include area code) ________________________________________________________


b

Widow(er)'s Date of Birth

c Widow(er)'s Date of Marriage to Employee


d

Is the widow(er) disabled for all regular employment?

(Check one)

Yes No


e

Were the employee and widow(er) living together at

the same address at the time of the employee's death?

(Check one)

Yes No


8

Was the employee survived by a divorced spouse to

whom he or she was married at least 10 years or who has

children of the employee in his or her care?

(Check one)

 Yes - Complete a-e, below

No - Go to Item 9


a

Divorced Spouse's Name, Mailing Address, and Telephone Number

Name _________________________________________________________________________________

Address _________________________________________________________________________________

_________________________________________________________________________________

Telephone Number (Include area code) ________________________________________________________


b

Divorced Spouse's Date of Birth

c Divorced Spouse's Date of

Marriage to Employee

d Divorced Spouse's Date of

Divorce from Employee


e

Is the divorced spouse disabled for all regular employment?

(Check one)

Yes

No


9

Was the employee survived by:



a

unmarried children under age 18? (Includes a

natural child, stepchild, adopted child, or

dependent grandchild.)

(Check one)

Yes

No


b

unmarried children who have been continuously

disabled since before age 22?

(Check one)

Yes

No


c

unmarried children age 18-19 who are full-time

students at an elementary or high school?

(Check one)

Yes

No


d

a parent age 60 or over who was dependent on

the employee for at least one-half support?

(Check one)

Yes

No


10

Enter all survivors for whom "Yes" is indicated in Item 9. If more space is needed, continue in Section 5.



Name, Mailing Address, and Telephone Number

Date of Birth

Relationship

To Employee



Month

Day

Year














Section 3

Information About Employee's Burial Expenses and Estate

Complete Items 11 through 15 only if the employee was not survived by a widow(er) who was living with the employee at the time of death. If there is more than one executor or payer of the burial expenses, etc., provide their name, address and telephone number in Section 5, Remarks.

11

Name, Mailing Address, and Telephone Number of the funeral director who buried the employee.

Name ____________________________________________________________________________________

Address ____________________________________________________________________________________

____________________________________________________________________________________

Telephone Number (Include area code) ___________________________________________________________

12

Name, Mailing Address, and Telephone Number of the person who paid or will pay the burial expenses.

Name ____________________________________________________________________________________

Address ____________________________________________________________________________________

____________________________________________________________________________________

Telephone Number (Include area code) ___________________________________________________________

13

Have all of the burial expenses been paid?

(Check one)

Yes

No

14


a. Did, or will, the payer of the burial expenses use his/her own funds (including a joint account with the deceased)?

(Check one)

Yes

No

b. 1. Did, or will, the payer of the burial expenses use the funds of the employee’s estate (including a trust agreement)?

(Check one)

Yes - If a Trust Agreement, complete Item 14b.2

No - Go to Item 14c

2. Provide the Name, Mailing Address, and Daytime Telephone Number of the Trustee(s). If more than one, continue in Section 5, Remarks.

Name _______________________________________________________________________________

Address _______________________________________________________________________________

_______________________________________________________________________________

Telephone Number (Include area code) ______________________________________________________

c. Did, or will, the payer of the burial expenses use the funds of others?

(Check one)

Yes - Explain below

No - Go to Item 15

Explanation:


15

a. Has a court appointed administrator or executor been appointed, or expected to be appointed? Answer "No" if someone has been named in the employee's will only.

(Check one)

 Yes - Complete Item 15b

No - Go to Section 4

b. Court Appointed Administrator's Name, Mailing Address, Telephone Number and Date of Appointment

Name __________________________________________________________________________________

Address __________________________________________________________________________________

__________________________________________________________________________________

Telephone Number (Include area code) _________________________________________________________

Date of Appointment ____________________________________________

Section 4

Information About Employee's Survivors

16

Give the information requested below about the employee's living relatives only if there are no survivors listed in

Item 10 or, if there is an "X" in the special instructions box on the first page of this form, give the information

requested below about the employee's Children. If no child survives, then the Grandchildren. If no grandchild

survives, then the Parents. If none of the preceding relatives survive, then the Brothers and Sisters (no date of

birth needed.)

Name, Mailing Address, and Telephone Number

Date of Birth

Relationship

to Employee

Month

Day

Year





















Section 5

Remarks

17

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 section to enter any additional information that you feel may be important to include.













Section 6

Certification

18

I understand that giving fraudulent, false or incomplete information to the Railroad Retirement Board to cause payment of benefits is a crime punishable by Federal law. I certify that the information that I have provided is true, correct and complete to the best of my knowledge.

Signature of Person Furnishing Information

Relationship to Employee

Number and Street Address

Daytime Telephone Number

( )

City, County, State and ZIP Code

Date

Month

Day

Year





Form RL-94F (10-18)


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleRL-94F (10-18)
SubjectForm Approved OMB No. 3220-0032
Authorstephph
File Modified0000-00-00
File Created2023-08-26

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