Form AA-4 (06-23) AA-4 (06-23) Self-Employment and Substantial Service Questionnaire

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

FORM APPROVED
OMB No 3220-0138

DO NOT WRITE IN THIS SPACE
APPROVED BY

SELF-EMPLOYMENT AND
SUBSTANTIAL SERVICE
QUESTIONNAIRE

Paperwork Reduction Act/Privacy Act Notices
The Railroad Retirement Board (RRB) is authorized to collect
the following requested information under Section 7(b)(6) of
the Railroad Retirement Act (RRA). This information is needed
to determine whether your self-employment will affect your railroad retirement benefits under the RRA. You are not required
to provide the information requested by this form. However,
your failure to provide us with the requested information may
result in our being unable to pay you any benefits.
The information you provide may be disclosed for purposes
of verification to the employer(s) named in item 8. A complete
listing of the persons, organizations and agencies to which
the information you give us may be released is available at
any office of the RRB.

We estimate this form takes between 40 and 70 minutes per
response, including the time 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
any comments regarding the accuracy of our estimate or any
other aspects of this form including suggestions for
improving the completion time, to the Associate Chief
Information Officer for Policy and Compliance, Railroad
Retirement Board, 844 North Rush Street,
Chicago, Illinois 60611-1275.

SECTION 1–GENERAL INSTRUCTIONS
Always complete Sections 1–3 and Sections 5–7 of this form. Complete Section 4, as applicable, as explained in the instructions at the beginning of that section. Print all answers in ink or use a typewriter. If you are completing this form on behalf of
someone else, you must answer each question as it applies to that person. If you need more space than is provided to answer
a question, use Section 6 for this purpose. If you do not know the answer to a question, print “unknown” in the space provided
for the answer. When entering dates, always use numbers. Also, be sure there is one number in each box. For example, you
would enter June 6, 2020, as:
MONTH

0

6

DAY

0

6

YEAR

2

0

2

0

SECTION 2–INFORMATION THAT IDENTIFIES YOU
Look over the information entered by the RRB for Items 1, 2 and 3 to be sure it is correct. If it is correct,
go to Item 4. If the information is not correct, line it out and enter the correct information.
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1. RAILROAD RETIREMENT BOARD CLAIM NUMBER

IDENTIFYING INFORMATION

2. RAILROAD EMPLOYEE’S SOCIAL SECURITY NUMBER
3. RAILROAD EMPLOYEE’S NAME
4. YOUR NAME
If you are also completing Form AA-1, Application for Employee Annuity or Form AA-3, Application for
Spouse/Divorced Spouse Annuity, go to Item 7. Otherwise complete Items 5 and 6.
5. MAILING ADDRESS
STREET ADDRESS
CITY AND STATE
ZIP CODE
6. DAYTIME TELEPHONE NUMBER (INCLUDE AREA CODE)


Form AA-4 (06-23) (DESTROY PRIOR EDITIONS)

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SECTION 3–INFORMATION ABOUT YOUR SELF-EMPLOYMENT

TYPE OF WORK

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7a

Enter the name of your business.

7b

Enter an “X” in the appropriate box to indicate your form of business.
J Corporation
J Sole Proprietorship
J Partnership
J Consultant
J Other (Describe): _________________________________

8a

Enter an “X” in the appropriate box to indicate your job title.
J Owner/Partner
J Project Manager/Team Leader
J Sales Person
J Officer of Corporation
J Consultant/Independent Contractor
J Minister
J Other (Describe): _________________________________

8b

Describe the service you perform and the skill level required.

8c

Enter the name(s) and address(es) of the persons or organizations for whom you perform this service. (As used
in this questionnaire, “person” means individual, organization, or company.)

9a

Are you a former employee of one or more
of the person(s) listed in Item 8c?

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FORMER SERVICE

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9b

List the name(s) of that employer(s).

10a

Is the service you perform the same as the
service you performed as an employee?

K Yes - Go to Item 9b
K No - Go to Item 11

K Yes - Go to Item 11
K No - Go to Item 10b

10b Explain how your current service differs from the service you performed as an employee.

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Form AA-4 (06-23)

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11

Where do you perform your service (i.e., home, your own office, premises of the “person” shown in Item 8c)?

12

Enter an “X” in the appropriate box:
Do you advertise your services?

PLACE OF SERVICE

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ADVERTISE

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K Yes
K No

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13

Enter the date you began performing
your service.

14a

Are your services scheduled to end?

MONTH

DAY

YEAR

K Yes - Go to Item 14b

SERVICE DATES

K No - Go to Item 14c
MONTH

14b Enter the date your services are scheduled
to end.

14c

Describe the agreement you have concerning the length of your service.

15a

Do you determine your own work hours?

DAY

YEAR

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SERVICE HOURS

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15b

K Yes - Go to Item 16a
K No - Go to Item 15b

Who determines your work hours?

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Form AA-4 (06-23)

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K Yes - Go to Item 16b
16a

Is your work activity supervised?

K No - Go to Item 17

16b Describe the extent to which you are supervised.

SUPERVISION

16c Provide the name and title of the person who supervises you.

17a

K Yes - Go to Item 17b

In your work activity do you supervise people?

K No - Go to Section 4

17b Explain why you supervise them.

17c Describe their duties.

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SECTION 4–INFORMATION ABOUT SUBSTANTIAL SERVICE
Only complete Items 18 through 20 (and Item 21 if your RRB annuity began before this year) if you are
claiming that you did not perform substantial service in self-employment for one or more months in that
year. Otherwise, leave these items blank and go to Section 5. (Note: This is the only section on this
form that may be left blank, as applicable.)

INVESTMENT

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18

19

Enter the approximate value of the business and
the percent of the business that you own.

$ ___________________
__________________ %

Enter the amount of your earnings from the business
that would continue based solely on the capital you
have invested in it without any service performed by you.

Form AA-4 (06-23)

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$ ___________________

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SUBSTANTIAL SERVICE

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20

21

Enter a monthly breakdown of
the amount of time you spent
in this employment this year. If
regular business hours varied
during certain months of the
year, state the reason for the
variance(s) (i.e., vacation, sickness, etc.) in Section 6.

Enter a monthly breakdown of
the amount of time you spent
in this employment last year. If
regular business hours varied
during certain months of the
year, state the reason for the
variance(s) (i.e., vacation, sickness, etc.) in Section 6.

JAN

FEB

MAR

APR

MAY

JUNE

JULY

AUG

SEPT

OCT

NOV

DEC

JAN

FEB

MAR

APR

MAY

JUNE

JULY

AUG

SEPT

OCT

NOV

DEC

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SECTION 5–INFORMATION ABOUT YOUR EARNINGS

NET INCOME

22

23

Enter a monthly breakdown of
your net earnings after deduction of allowable business
expenses under each month of
this employment performed
this year.

Enter a monthly breakdown of
your net earnings after deduction of allowable business
expenses under each month of
this employment performed
last year.

JAN

FEB

MAR

APR

MAY

JUNE

JULY

AUG

SEPT

OCT

NOV

DEC

JAN

FEB

MAR

APR

MAY

JUNE

JULY

AUG

SEPT

OCT

NOV

DEC

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INCOME REPORT

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24a

24b

K Yes - Go to Item 24b

Are the payments you receive reported to the
Internal Revenue Service (IRS) by the person(s)
for whom you perform the services?

K No - Go to Item 25

How are the payments reported to the IRS (i.e., as wages, non-employee compensation, etc.)?

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Form AA-4 (06-23)

SELF EMPLOYMENT TAXES

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25a

Do you pay self-employment tax based on the income
received for the services you provide?

K Yes - Go to Item 26
K No - Go to Item 25b

25b State the reason you do not pay self-employment taxes.

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K Yes - Go to Item 26b

26a Do you participate in a fringe benefit program
(i.e., group medical insurance) of the person
named in Item 8c?

K No - Go to Item 27

FRINGE BENEFITS

26b Describe the fringe benefits.

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27a

K Yes - Read ‘Note’ then

Is there a written contract in accordance with
which you perform your services?

Go to Item 28

K No - Go to Item 27b
Note: If answered “Yes,” you must submit a copy of the contract.

CONTRACT

27b Describe the verbal agreement.

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LOSS

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28

Enter an “X” in the appropriate box:

K Yes

Do you risk personal financial loss in your business?

K No

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K Yes - Go to Item 29b

29a Do you receive money for your services?

NATURE OF PAYMENT

K No - Go to Item 29c
J Weekly J Bi-Weekly J Monthly
J Other (Describe): ____________________

29b Indicate your pay schedule, then go to Item 29d.

29c Describe the payment or reimbursement you receive for your services.

29d List any expenses you have that are not reimbursed.

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SECTION 6–REMARKS
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.
30

REMARKS

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Form AA-4 (06-23)

CERTIFICATION

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SECTION 7–CERTIFICATION
31 I certify that all the information I have provided in completing this form is true to the best of my knowledge. I
know that if I have made a false or fraudulent statement on this form or if my refusal to provide this information
reflects a fraudulent intent to obtain benefits not authorized by law, I am committing a crime which is punishable
under Federal law by fine or imprisonment or both.

SIGNATURE
(First Name, Middle
Initial, Last Name)
MONTH

DAY

YEAR

DATE
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32 If this certification is signed by mark (“X”) in Item 31, two witnesses who know the person signing must sign
below, giving their full addresses and daytime telephone numbers.
a. Signature of Witness

Address (Number and Street)

WITNESSES

City, State, ZIP Code

Area Code

Telephone Number

Area Code

Telephone Number

Daytime Telephone Number
b. Signature of Witness

Address (Number and Street)

City, State, ZIP Code

Daytime Telephone Number
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MAIL THIS QUESTIONNAIRE TO THE ADDRESS SHOWN BELOW. MOST RAILROAD RETIREMENT BOARD
OFFICES ARE OPEN TO THE PUBLIC FROM 9:00 AM THROUGH 3:00 PM MONDAY THROUGH FRIDAY.

REFER ANY QUESTIONS TO:
Form AA-4 (06-23)

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