RL-94F (XX-XX) Survivor Questionnaire

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)