AA-1d Application for Determination of Employee Disability

CURRENT

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002
Do Not Write In This Space
Officially Filed

Month

Application
For Determination
Of Employee’s Disability

Day

Year

Office Number

Approved

Application Number

Month

Date Coded
Day

Year

Coded by

Section 1

General Instructions

Before you complete this application, be sure to read Part 1 of booklet RB-1d, Employee Disability Benefits, which explains information
you will need to answer many of the questions in this application. Please read “Important Notices” on page 15 of this application.
Print legibly in ink. If you need more space than is provided to answer a question, use Section 9, Remarks, 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, 2016, as:
Month

Day

Year

0 6 0 6 2 0 1 6
Some items in this application 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 or even another section. Follow the instructions that tell you to
“Go to” another item. These are designed to save you time and help you move through the application form quickly, filling
in only necessary information. If no “Go to” instructions are given, answer the next item in order. Do NOT skip any items
unless directed to do so.
If you are completing this application on behalf of someone else, you must answer each question as it applies to the
applicant.

Section 2

Identifying Information

Check the information entered by the Railroad Retirement Board (RRB) for Items 1 through 5 for accuracy.
 If the information is correct, go to Section 3.
 If the information is not correct, enter the correct information.
 If the information is missing, fill it in.
Employee
1 Employee’s Name
Identification

2 Employee’s Railroad Retirement Claim Number

3 Employee’s Social Security Number

A
4a Employee’s Street Address

b City and State/Province

5a Daytime Telephone Number

(

)

c ZIP Code

d Country

b Alternate Telephone Number

(

)
Form AA-1d (05-17) Destroy Prior Editions

Section 3

6 Describe the medical condition(s) causing you to file. Enter the exact primary diagnosis if known and any additional
condition(s). Also enter if no medical records are being forwarded for each condition described.
Yes



No

Additional Condition(s)

Medical Attached



Yes



No

When
Condition
Began

7 Enter the date the condition(s) began to affect
your ability to work.



How
Condition
Affects
Work

8 Enter an “X” in the appropriate box:
Have you worked since the date in Item 7?






Yes





Go to Item 9

No



Medical Attached

Go to Item 10

9a Enter an “X” in the appropriate box:
Has your condition caused you to change any aspect of your
work (such as job duties, hours of work, attendance, etc.)?






Yes



Primary Condition

Go to Item 9b

No



Medical
Condition

Information About Your Medical Condition

Go to Item 10

Month

Day

Year

b Explain what the changes in your work circumstances were, the dates they occurred, and why your condition(s)
made these changes necessary.
CHANGES

When
Unable
To Work

DATES

10 Enter the date you could no longer work
because of your condition(s).

CONDITION



Month

Day

Year

11 Describe how your condition(s) prevents you from working.

Current
Work
Status

12a Enter an “X” in the appropriate box:
Did you attempt to go back to work and were you
unable to do so?
b Enter the date(s) of the work attempts

Form AA-1d (05-17) Page 2






Yes



Go to Item 12b

No



Go to Section 4

Section 4

Information About Your Medical Care

Medical
13a Enter an “X” in the appropriate box:
Care or
Have you received medical care or been examined for
Examination

your condition(s) since the date in Item 7?

15b Enter an “X” in the appropriate box:
Are you scheduled for any additional medical care for your
condition(s) (i.e., surgeries, etc.) after you file this application?






Yes






Yes



Explain below

No



Go to Item 14






Yes



Go to Item 15

No



Go to Item 16

No

Explain:

Treatment
or Testing

14 Enter an “X” in the appropriate box:
Have you been treated or tested (inpatient or outpatient)
at a hospital, institution, or clinic, including a
Department of Veterans Affairs or other government
facility?

15 Enter information about each hospital, institution, or clinic where you have received treatment or care since the
date in Item 7.
Address of Facility (Street Address, City, State/Province, and
ZIP Code)

a Name of Facility

Attending Physician’s Name

Enter an “X” in the appropriate box:
Inpatient



Outpatient 
Telephone Number (Include Area Code)

Patient Number

(
Dates Treated or Tested

)

Describe Type of Treatment or Testing

Address of Facility (Street Address, City, State/Province, and
ZIP Code)

b Name of Facility

Attending Physician’s Name

Enter an “X” in the appropriate box:
Inpatient



Outpatient 

Patient Number

Telephone Number (Include Area Code)

(
Dates Treated or Tested

)

Describe Type of Treatment or Testing

Form AA-1d (05-17) Page 3

Treatment
or Testing
(Cont)

15c

Name of Facility

Address of Facility (Street Address, City, State/Province, and
ZIP Code)

Attending Physician’s Name

Enter an “X” in the appropriate box:
Inpatient



Outpatient


Telephone Number (Include Area Code)

Patient Number

(
Dates Treated or Tested

Doctor
Treatment

)

Describe Type of Treatment or Testing

16 Enter an “X” in the appropriate box:
Has your personal physician or other doctor treated
you since the date in Item 7?






Yes



Go to Item 17

No



Go to Item 18

17 Enter information about each personal physician or other doctor who has treated you.
a Name of Physician

Patient Number

Address of Facility (Street Address, City, State/Province, and
ZIP Code)

Telephone Number (Include Area Code)

(
Dates Treated or Examined

b Name of Physician

Patient Number

Address of Facility (Street Address, City, State/Province, and
ZIP Code)

Telephone Number (Include Area Code)

(
Dates Treated or Examined

Form AA-1d (05-17) Page 4

)

Describe Type of Treatment or Examination

)

Describe Type of Treatment or Examination

Name of Physician

Address of Facility (Street Address, City, State/Province, and
ZIP Code)

Patient Number

Telephone Number (Include Area Code)

(

)

Describe Type of Treatment or Examination

Railroad
18 Enter an “X” in the appropriate box:
Employer
Has your railroad employer referred you to a medical source
Examination

for examination or treatment within 18 months of filing this
application?




Yes



Dates Treated or Examined

Go to Item 19

No



17c



Doctor
Treatment
(Cont)

Go to Item 20

19 Enter information about this examination or treatment.
Name of Medical Source

Address of Source (Street Address, City, State/Province, and
ZIP Code)

Attending Physician’s Name

Enter an “X” in the appropriate box:


Telephone Number (Include Area Code)

Patient Number

(
Dates Treated or Examined

)

Describe Type of Treatment or Examination

20 Enter an “X” in the appropriate box:
Have you been medically disqualified for work by your employer?




Yes



Outpatient

Go to Note and Item 21

No







Inpatient

Go to Item 21

Yes






Go to Item 22

No



21 Enter an “X” in the appropriate box:
Has a medical doctor restricted your daily activities since the
date in Item 7?

Go to Item 25

22 Enter the name of the medical doctor who imposed the restriction. Also enter the medical doctor’s address if it has not
previously been entered in items 16, 18, or 20.
Name of Medical Doctor

23 Enter the date the restriction began.

Address of Medical Doctor (Street Address, City, State/Province,
and ZIP Code)



Activity
Restriction



Note: If answered “Yes,” you must submit a copy of the Disqualification Notice.

Month

Year

Form AA-1d (05-17) Page 5




Yes



25a Enter an “X” in the appropriate box:
Are you currently taking prescribed medication(s)?

Go to Item 25b

No



Medication

24 List and describe the condition(s) and how your daily activities were restricted by the condition(s).



Activity
Restriction
(Cont)

Go to Section 5

b Enter from the prescription labels the following information for all medications prescribed for you:
Name or type of medication, dosage, and frequency. (For example, Penicillin, 1.5 gram tablet, 3 times a day.)
Name / Type

b Enter the date you began attending.



Go to Item 27b

No



Go to Item 28

Technical
Specialized
Vocational
Services:
Other:
Month





Skip Item 28 and go to Item 29b.

29a Enter an “X” in the appropriate box:
Have you attended technical school, or received
specialized/vocational training or services?

Yes

to Present







c Enter an “X” in the appropriate box:
Indicate what type of school you are attending or
enter the services you receive. Use “Other” to
indicate any other type of school not listed.

28 Enter the date that you last attended school.







Day

Yes



27a Enter an “X” in the appropriate box:
Are you currently attending school (including online)?

Go to Item 29b

No



26 Enter the highest grade of school you completed.



Information About Your Education And Training



Schooling

Frequency



Section 5

Dosage (Grams, Number of Pills, Etc.)

Go to Item 30

Year

b Describe the type of technical school you attended, or training or services you received and the period of time you
attended or received the training.
Type

Form AA-1d (05-17) Page 6




Yes



Go to Item 31

No



Go to Section 6




Yes




Yes





To

Go to Item 33

No



32 Enter an “X” in the appropriate box:
Have you used any of this training in your work?



31 Enter an “X” in the appropriate box:
Is the degree, certificate, or license you received currently valid?



30 Enter an “X” in the appropriate box:
Have or will you receive a degree, certificate, or license for any
training you received?

From

Go to Section 6

No

33 Describe when and how you have used this training in your work.

Information About Your Daily Activities

Section 6

34 Check the one box after each activity listed below that best describes your ability to do that activity.
• EASY - I can easily do the activity.
• DIFFICULT - I can do the activity with difficulty.
• HARD - I can only do the activity with assistance.
• NOT AT ALL - I cannot do the activity with assistance.
• N.A. - Not applicable











Standing











Walking











Eating











Bathing











Dressing (Tying Shoes,
Combing Hair, etc.)











Other Bodily Needs











Indoor Chores (Meal
Preparation, Laundry,
Cleaning, etc.)











Outdoor Chores
(Shopping, Yardwork, etc.)











Driving a Motor Vehicle











Using Public Transportation











Conducting Personal
Business (Talking to
and Dealing with Other
People)











Reading English (For
example, newspapers and
magazines)











Writing English (For
example, notes and
letters)

























Sitting



Explain each “DIFFICULT,” “HARD,”
and “NOT AT ALL” answer



N.A.



Not
At All



Easy Difficult Hard



Activity



Activities



Schooling
(Cont)

Form AA-1d (05-17) Page 7




Yes
No



36a Enter an “X” in the appropriate box:
Do you perform any volunteer work?
(Volunteer work is any work performed without pay.)

Go to Item 36b



35 Describe your daily activities during a normal day (i.e., a typical day from the time you get up until you go to bed).



Activities
(Cont)

Go to Item 37

b Describe the volunteer work that you perform and enter the number of average hours you participate per week.
Volunteer Work




Yes



Go to Item 36d

No



Go to Item 37




Yes



Go to Item 37b





c Enter an “X” in the appropriate box:
Does your condition(s) restrict your ability to perform
volunteer work?

Average Hours Per Week

Go to Section 7

37a Enter an “X” in the appropriate box:
Do you participate in social or recreational activities?
For example, clubs, traveling, exercise, indoor/outdoor sports,
hobbies/crafts, etc.



d Describe the changes.

No

b Describe the social or recreational activities that you participate in and enter the number of average hours you participate per week.

d Describe the changes.

Form AA-1d (05-17) Page 8

Yes
No






Go to Item 37d



c Enter an “X” in the appropriate box:
Does your condition(s) restrict your participation in the
activities listed above?

Average Hours Per Week



Activity

Go to Section 7




Yes



Work for an 38 Enter an “X” in the appropriate box:
Employer
Have you worked and received pay from a railroad or nonrailroad
Last 12
employer in the last 12 months? (Do not include any self-employment.)
Months

Go to Item 39

No



Information About Your Work And Earnings


Section 7

Go to Item 40

39 Enter your earnings before any deductions for each month you have already worked this year. Then starting with the
current month, enter your expected gross earnings for this month and each remaining month this year.
January

February

March

April

May

June

July

August

September

October

November

December

May

June

November

December

Work for an 40 Enter your earnings before any deductions for each month last year.
Employer
Previous
January
February
March
April
Calendar
Year




Yes



Yes






Go to Section 8

Go to Item 52
Go to Item 46
Go to Note and Item 47
Go to Item 48

45 Enter an “X” in the appropriate box:
Are you filing Form AA-1 at this time?

Self46 Enter an “X” in the appropriate box:
Employment

Have you been self-employed in the last 12 months?



General Information



Filing
AA-1

No

Go to Item 42





44 Enter the gross amount you expect to earn.
(If you are self-employed, enter the
net amount.)

Section 8

Yes



43 Enter the date(s) you expect to work.
(For example: “June and July”;
Indefinitely starting 6-16; etc.)



42 Enter the name and address of the person or
company for whom you expect to work.
(If self-employed, enter “Self.”)






41 Enter an “X” in the appropriate box:
Do you expect to work during the next 12 months?
(Include self-employment, if any.)

October



September



Work
Next 12
Months

August



July

No

No

Note: If answered “Yes,” also complete and return to the RRB Form AA-4, Self Employment Questionnaire.
Form AA-1d (05-17) Page 9




Yes
No

 

corporation?



Self47 Enter an “X” in the appropriate box:
Employment
Are you a corporate officer or owner/operator of a
(Cont)

Go to Note and Item 48
Go to Item 48

Yes
No



expect to receive, worker’s compensation payments?




Go to Note and Item 49



Worker’s
48 Enter an “X” in the appropriate box:
Compensation
Since the date in Item 7, have you received, or do you



Note: If answered “Yes,” also complete and return to the RRB Form G-252, Self-Employment/Corporate
Officer Work and Earnings Monitoring.

Go to Item 49




Yes
No



49 Enter an “X” in the appropriate box:
Since the date in Item 7, have you received, or do you
expect to receive, disability benefits under a Federal,
state, or local government plan or law based on
employment not covered under the Social Security Act?
(Answer “No” if your benefits are railroad retirement, social
security, Veterans Affairs or welfare benefits.)

Go to Note and Item 50



Public
Disability
Benefits



Note: Proof of the amount(s) and effective date(s) of your worker’s compensation are required.

Go to Item 50

57 Enter an “X” in the appropriate box:
Is your disability related to your confinement?

58 Enter an “X” in the appropriate box:
Has the confinement ended?

59 Enter the date the confinement ended.
Form AA-1d (05-17) Page 10




Go to Item 53
Go to Section 9

Month

Day

Year

Month

Day

Year

Month

Day

Year



No



Yes

Go to Item 52




Yes
No




Yes




Yes

No

No

 

56 Enter the date that confinement began.




No

Go to Item 51





55 Enter the date of the sentence of confinement.



54 Enter an “X” in the appropriate box:
Is your disability related to the commission of the
criminal offense?

Yes



53 Enter the date of the conviction.






52 Enter an “X” in the appropriate box:
Within the past 12 months, have you been imprisoned or
given a sentence of confinement due to a conviction for a
criminal offense?



51 Enter the social security claim number under which you
have filed or will file.



Criminal
Offenses

50 Enter an “X” in the appropriate box:
Have you filed, or do you expect to file, for monthly social
security disability benefits or Supplemental Security Income?



Social
Security
Benefits



Note: Proof of the amount(s) and effective date(s) of your public disability are required.

Go to Item 59

Month

Day

Go to Section 9
Year

Section 9
Remarks

Remarks

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

Form AA-1d (05-17) Page 11

Relinquishment Of Rights By Disability Annuity Applicant Only

Section 10

I authorize the RRB to relinquish any rights I may have to return to work for a railroad employer, which will affect the
payment of my own or my spouse’s annuity. Based on this authorization, my rights will be relinquished when I reach full
retirement age (FRA) or at age 60-FRA if I become entitled to a supplemental annuity or if my spouse becomes entitled
to a spouse’s annuity. I understand this authorization remains in effect unless my disability annuity terminates before FRA
or before a supplemental or spouse’s annuity becomes payable. My rights will also be relinquished if I am eligible for a
reduced age and service annuity and choose to receive this type of annuity if my disability is denied.

Section 11



Go to Item 61b

No



Go to Item 62




Yes




Yes



62 Enter an “X” in the appropriate box:
Will you have a guardian or other representative sign this
application on your behalf?

Yes

Go to Note and Item 63

No



c Did you pay a fee to the attorney or non-family member
who assisted with completing this application?




Go to Item 63



b Enter the name and address of the attorney or non-family
member who assisted with completing this application.



attorney or non-family member (RRB staff excluded)?



Certification 61a Did you complete this application with the assistance of an



Certification

No

Note: If answered “Yes,” the guardian or other representative of the applicant must sign this application.
That person must also complete and return Form AA-5, Application for Substitution Of Payee.
63 I certify that the information I gave the Railroad Retirement Board (RRB) on this application is true to the best of my
knowledge. I know that if I make a false or fraudulent statement or withhold information in order to receive benefits from
the RRB, I am committing a crime under Federal law which may be punishable by fines, imprisonment, or both. I
have received and reviewed the booklets, RB-1d, Employee Disability Benefits, and RB-9, Employee and Spouse
Annuities Events That Must Be Reported. I understand that I am responsible for reporting events that would affect
my annuity as explained in the booklets.
I agree to immediately notify the RRB:
• If I work for any employer, railroad or nonrailroad, or perform any self-employment work;
• If my condition improves;
• If I am confined in a jail, prison, penal institution, or correctional facility due to a conviction for a criminal offense;
• If I begin to receive worker’s compensation payments (or any other public benefit based on disability),
or if the amount of my payment changes;
• If my address changes.
• If I have a claim or a settlement related to my condition(s).

Signature
(First Name, Middle Initial,
Last Name)



I know that if I am receiving a disability annuity and fail to report work and earnings promptly, I am committing
a crime punishable by Federal law that may result in criminal prosecution and/or penalty deductions in my
annuity payments.

Day

Year



Month

Date

64 If this certification is signed by mark (“X”) in Item 63, two witnesses who know the person signing must sign below,
giving their full addresses and daytime telephone numbers.
a. Signature of Witness

b. Signature of Witness

Address (Number and Street)

Address (Number and Street)

City, State/Province, and ZIP Code

City, State/Province, and ZIP Code

Daytime Telephone Number (include area code)

Daytime Telephone Number (include area code)

(

(

)

Form AA-1d (05-17) Page 12

)

Section 12

How To Return Your Application





Every question that applies to you has been answered.







You have entered “Unknown” in any answer space for which you were unable to answer a question.





You have signed and dated the application.





You have included all the needed proofs listed in the letter you received with this application.







Before you return your application, check to make sure that:

When you received your application, you should also have received a pre-addressed return envelope. If you do
not have this envelope, you can use any envelope as long as it is addressed to the RRB office shown on page
14. No matter which envelope you use, you must put the correct postage on the envelope. Be careful to provide
enough postage, because your application and the accompanying forms may weigh more than a standard letter.
The U.S. Postal Service will not deliver your application unless it has the correct postage.





NEEDED PROOFS





THE APPLICATION FORM ITSELF





ADDITIONAL FORMS YOU WERE ASKED TO COMPLETE







Make one final check before you seal the envelope to ensure that the following are enclosed:

Note: Make no entries on page 14, which is the receipt for your claim. After the RRB receives your
application, they will complete the blanks on the receipt and send it back to you. When it is returned
to you, you will know that the RRB has received your application and has started the work needed to
determine if you are entitled to benefits. If you do not receive the receipt within a month after you filed
this application, please contact us so we can find out what is causing the delay.

Form AA-1d (05-17) Page 13

Receipt For Your Claim
Employee Applicant’s Name

Date Claim Received

Your application for railroad retirement disability benefits has been received and will be processed as quickly
as possible. If you change your address or if there is some other change that may affect your claim, you or
your representative should report the change. The changes to be reported are listed below. Always give us
your claim number when writing or calling about your claim. If you have any questions about your claim, we
will be glad to help you.
If you need to personally visit one of our field offices, please call for an appointment. You will not be refused
service if you do not have an appointment, but our staff can serve you better when an appointment is made.
Offices are open to the public 9:00 AM to 3:30 PM daily, except Wednesday 9:00 AM to 12:00 PM and closed
Federal Holidays.

Always Report These Changes to the RRB
• WORK – If you work for any employer, railroad or nonrailroad, or perform any self-employment work.
• CONDITION – If your condition improves.
• WORKER’S COMPENSATION (or any other benefit based on disability) – If you begin to receive
worker’scompensation payments (or any other public benefit based on disability), or if the amount of your
payment changes.
• CRIMINAL OFFENSE – If you are confined in a jail, penal institution, or correctional facility due to a conviction
for a criminal offense.
• ADDRESS – If your address changes.
• LIABILITIES – If you have a claim or a settlement related to your condition(s).

How To Report Changes
When a change occurs after you are entitled to disability benefits, you should report the change at once. You can make your
reports by telephone, mail, or in person, whichever you prefer.



To report any of the above changes, contact:



Telephone Number:



If for some reason you cannot contact that office, you should contact:

US RAILROAD RETIREMENT BOARD
844 N RUSH STREET
CHICAGO IL 60611- 1275

Form AA-1d (05-17) Page 14

Important Notices

PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICES
This notice is given under the Paperwork Reduction Act of 1995 and the Privacy Act of 1974. The Privacy Act requires that the
Railroad Retirement Board (RRB) tell you the following whenever we ask you for information.
1)
2)
3)
4)

The law which allows us to ask for the information;
whether that law requires you to give us that information and what, if anything, might happen to you if you do not give it to us;
the reason why the information is requested; and
the persons, organizations, and agencies to which we may release the information without your permission.

The RRB’s authority for requesting this information is Section 7(b) of the Railroad Retirement Act (RRA) of 1974. Providing us
with this information is voluntary on your part. However, if you fail to provide us with the requested information we may be unable
to pay you any benefits. The RRB needs this information to determine whether or not you are eligible to receive such benefits
and, if so, the amount you are entitled to receive. If your annuity application is approved and we begin to pay you benefits,
information that we may request from you in the future will be used to determine whether you are entitled to continue to receive
such benefits.
Although the information we request is almost never used for any purpose other than the payment of benefits under the RRA,
the RRB does have the authority to release the following information to the indicated individuals, organizations, and/or agencies
without your approval:
1)
2)
3)

4)
5)
6)

7)

8)
9)
10)
11)
12)
13)
14)
15)

Information may be released to an attorney, the Office of the President, a Congressional office, a labor union or the
Department of State’s embassy or consular offices if they allege to be representing you at your request.
Information may be released to other people who are receiving benefits based on the same railroad retirement account
as you are, if the information affects their payments from the RRB.
Information may be released to a person who will receive benefits on your behalf if the RRB decided that some medical
condition keeps you from receiving your own benefits; such information may also be released in determining whether
such a medical condition exists and who is suitable to receive such benefits for you.
Information (including medical records) may be released to people or organizations who are working for the RRB.
Information may be released to the U.S. Treasury Department or Postal Service to issue payments and to investigate
lost, forged, or stolen payments.
Information may be released to your last employer to make sure that you are eligible to receive railroad retirement benefits
and you continue to receive any available medical benefits, and to any railroad employer (or to its insurance company) to make
sure that you can receive any private retirement or insurance benefits which may be offered by the employer.
Information may be released to the Social Security Administration, Centers for Medicare & Medicaid Services, Pension
Benefit Guarantee Corporation, Office of Personnel Management, Department of Veterans Affairs, or Federal, State, or local
welfare or public aid agencies to determine if you can receive benefits from their organizations and if any previous benefits
were paid incorrectly.
Information may be released to the Internal Revenue Service or to State and local taxing authorities for figuring your
taxes and for use in audits.
Your last address and the name of your last employer may be released to the Department of Health and Human Services to
be used in the Parent Locator Service.
Information may be released to the Government Accountability Office for audits and for collecting overpayments owed to the
RRB or Social Security Administration.
Information may be released to the U.S. Department of Labor as required by the Federal Coal Mine and Safety Act.
Information may be released in certain cases for law enforcement purposes and for court proceedings.
Information about the determination and recovery of an overpayment made to you may be released to any other person
from whom any portion of the overpayment is being recovered.
Your name and address may be released to a Member of Congress to inform you about current or proposed legislation
which could affect the railroad retirement system.
Information may be released to Professional Standard Review Organizations and State Licensing Boards when services
provided by physicians or practitioners suggest unethical or unprofessional conduct.

We estimate this form takes an average of 60 to 85 minutes per response to complete, 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 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.

Computer Matching And Privacy Protection Act Notice
The Computer Matching and Privacy Protection Act of 1988 requires the RRB to advise you that information you have provided
may be used, without your consent, in automated matching programs. These matching programs are a computer comparison
of RRB records with records kept by other Federal, State, or local governmental agencies. Information from these matching
programs can be used to establish or verify a person’s eligibility for federally funded or administered benefit programs and for
repayment of payments or delinquent debts under these programs.
Form AA-1d (05-17) Page 15