AA-1sum (12-17) (C Application Summary

United States of America
Railroad Retirement Board

CURRENT (COMPLETED)

Form Approved
OMB No. 3220-0002

APPLICATION SUMMARY FOR A DISABLED EMPLOYEE ANNUITY
RRB Claim Number
Name
Social Security Number

A 123-45-6789
John Doe
123-45-6789

The following information was either supplied by or verified by you in support of your
application for a Disabled Employee 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, which may be punishable by fines, imprisonment or both.
Military Service
I was in active military service.
Recent Employment

I did not work for an employer outside the railroad industry during the last six months
or since leaving the railroad industry.
Railroad Employment

You have a current connection with the railroad industry.
I have worked for the following railroad, railroad labor organization or other employer in
the railroad industry.
Railroad Name
Date Last Worked
Date Rights Relinquished
Union Pacific Railroad
09/30/2011
09/30/2011
Name and Address

John Doe
123 Ave St.
Marathon Fl 02202

Daytime Telephone Number
Alternate Telephone Number

555-123-4567
555-765-4321

Date of Birth

08/28/1928

Type of Application Filed

Disability Employee Annuity

Application Filing Date
RRB Form AA-1sum (12-17)

01/25/2017
81311 19200 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

I am applying for a benefit based on my age and railroad service.
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.
Marriages
I am currently married or separated.
Family
I do not have unmarried qualifying children.
I am expecting a newborn. Expected delivery date: 10/01/2017.
Other Government Benefits
I am currently receiving a social security benefit.
I have not filed nor do I plan to file in the next three months for social security benefits on
an additional account number.
In the past month I have not filed nor do I plan to file in the next three months for railroad
retirement benefits on any other account number.
I am not receiving nor do I expect to receive a pension or lump-sum payment based on
my earnings after 1956 from an employer not covered by social security or railroad
retirement.
Other Benefits
I expect to receive a railroad pension or lump-sum payment from Union Pacific Railroad.
Miscellaneous Information
The RRB has not been furnished with a court order to enforce my child support or alimony
obligation.
The RRB has not been furnished with a court order to pay part of my present or future
railroad retirement benefit to a spouse or former spouse as part of a property settlement in
a divorce or legal separation proceeding.
I had living with me at least one of my own or my spouse’s children, who was under age 3.
I have not received nor do I expect to receive pay for time lost from my last railroad
employer.

RRB Form AA-1sum (12-17)

81311 19200 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

I have not received nor do I expect to receive sick pay under a wage continuation plan,
established through company policy or a labor agreement, for a period after the actual day
I last worked.
I have not filed nor do I expect to file a lawsuit or claim against any person or company for
a personal injury where I also received sickness benefits as a result of that injury.
Criminal Offense Information
Within the past 12 months I have not been imprisoned or been given a sentence of
confinement due to a conviction for a criminal offense.
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.
Your application for a Disabled Employee Annuity has been released and will be
processed as quickly as possible. If you do not receive notification about your application
by October 1, 2016, you should contact the field office shown below.
You have received and reviewed the booklets RB-1, Age and Service Employee Annuity,
RB-1d, Employee Disability Benefits, and RB-9, Employee and Spouse Annuities - Events
that Must be Reported. It is your responsibility to report events that would affect your
annuity as explained in the booklets. Failure to report any of the events listed below or
other events that may affect your annuity may result in a penalty deduction from your
annuity, as well as criminal and/or civil prosecution.
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
12:00PM Wednesday.
Always Report These Changes to the RRB
 Railroad Work – If you return to work for a railroad or railroad labor organization or
return to work in any capacity in the railroad industry.
 Social Security – If you file for social security benefits based on any person’s
earnings record.
 Social Security – If benefits you receive directly from the Social Security
Administration are adjusted for a reason other than normal cost-of-living increases.

RRB Form AA-1sum (12-17)

81311 19200 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

 Public Pension – If you receive a lump-sum payment or begin to receive a pension
based on earnings not covered by the Social Security Administration or Railroad
Retirement Board.
 Pension – If you receive a lump-sum payment or begin to receive a monthly pension
from your railroad employer.
 Other Benefits – If you begin to receive worker’s compensation or a public disability
benefit.
 Settlement – If you receive a settlement with credit for railroad service as “pay-fortime-lost” for months after 9/30/2012.
 Employment – If you perform work, including self-employment, for a family owned,
controlled or managed business, including a business operated, managed or owned
by you, a family member, friend or close associate, whether for pay or not, and without
regard to how the business is organized (e.g., sole proprietorship, partnership,
corporation, LLC, etc.).
 Employment – If you become a corporate officer of, own or operate a corporation
(including a corporation owned by a family member or friend), whether for pay or not.
 Employment – If you receive anything of value in lieu of salary or wages for any work
that you performed.
 Earnings – If you work for any employer or perform any self-employment work.
 Earnings – If your earnings change.
 You told us you expect your total nonrailroad earnings for 2017 to be less than
$15,720.
 You are not earning more than $1,310.
 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.
 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.
 Spouse – If your spouse who is receiving a benefit dies or your marriage ends in
divorce or annulment.
 Child – If a qualifying child marries or leaves your custody or residence.
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
RRB Form AA-1sum (12-17)

81311 19200 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

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;
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-1sum (12-17)

81311 19200 22000 06051 32704

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