Receipt for Claim

United States of America
Railroad Retirement Board

Current (ALL POSSIBLE)

Form Approved
OMB No. 3220-0002

Application Summary
Identifying Information
Employee's Name
Employee's Email
Sex
If different, enter your name at birth
Date of Birth
Does your name match the name on your Social Security (SSA) Card?
Name on SSA Card
Mailing Address
Do you currently live outside of the United States?
Address 1
Address 2
City
State/Province
ZIP/Postal Code
Country
Daytime Telephone Number
Alternate Telephone Number
Information About Type of Annuity
What type of annuity are you applying for?
Will you accept a reduced age annuity if you are not eligible for a full age annuity?
Do you want your annuity to begin on the earliest date permitted by law?
Information About You and Your Family
Select your current marital status
Where you previously married?
Are you expecting a new born?
Expected Delivery Date
Do you have children who are unmarried and meet any of the following conditions?
Under Age18
Number of children
Age 18 through 19 and attending elementary or secondary school full-time.
Number of children
Age 18 or older with a continuing disability that began before age 22 and prevents any kind
of employment.
Number of children
Name

Relationship to Employee

Information About Your Railroad Work
Organization Name
RRB Form AA-1int (12-17)

Employment Begin Date

Employment End Date
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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

Information About Your Nonrailroad Work
Did you work for pay outside the railroad industry either during the last 6 months you worked
in the railroad industry or after you left the railroad industry?
Were you self employed in a non-incorporated business during your last 6 months in the
railroad industry or after you left the railroad industry?
Employer Name

Employment Begin Date

Employment End Date

Information About Your Earnings
Earnings for (Prior Year)
Do you expect your annuity to begin before January 1, (Current Year)?
Were your total earnings from all employment in (Prior Year) more than $(Prior year annual
exempt amount)?
Enter your total earnings for (Prior Year)
Did you earn more than the (Prior Year) monthly earnings exempt amount of $(Prior year
monthly exempt amount) in all employment in every month of (Prior Year)?
Indicate each month in (Prior Year) which you did not earn more than the monthly earnings
exempt amount from all employment.
JAN FEB MAR APR MAY JUN
JUL AUG SEP OCT NOV DEC
Earnings for (Current Year)
Do you expect your total earnings from all employment in (Current Year) to be more than
$(Current year annual exempt amount)?
Enter the total amount you expect to earn (Current Year)
Do you expect to earn more than the monthly earnings exempt amount of $(Current year
monthly exempt amount) in employment for hire, or to perform substantial services in selfemployment in every month (Current Year)?
Indicate each month in (Current Year) which you do not expect to earn more than the
monthly earnings exempt amount from all employment.
JAN FEB MAR APR MAY JUN
JUL AUG SEP OCT NOV DEC
Earnings for (Next Year)
Do you expect your total earnings from all employment in (Next Year) to be more than $(Next
year annual exempt amount)?
Enter the total amount that you expect to earn (Next Year).
Indicate each of the first four months in (Next Year) which you expect to earn LESS than the
(Next Year) monthly earnings exempt amount of $ (Next year monthly exempt amount).
JAN FEB MAR APR

RRB Form AA-1int (12-17)

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

Information About Your Pay For Time Lost And Sick Pay
Pay For Time Lost
Did you receive or expect to receive pay for time lost from your last railroad employer?
Note: If answered "Yes" and you received an injury settlement or elected to receive
"dismissal pay", you will need to provide a copy of your settlement or election with your
application.
Select the dates for which those payments were made or will be made.
Railroad Sick Pay
Did you receive or expect to receive sick pay under a railroad wage continuation plan (other
than your own regular salary) that was established through a company policy or labor
agreement and this pay was for a period of time after the actual date you last worked for the
railroad?
Enter the dates for which these payments were made or will be made for up to 6n months
after your actual day last worked.
Enter the name of the sick pay plan, if known
Have you filed or do you expect to file a lawsuit or claim against any person or company for a
personal injury where you also received sickness benefits as a result of that injury?
Name of the person/company
Currently reside outside of the United States?
Address 1
Address 2
City
State
ZIP Code
Information About Garnishment, Criminal Offense, and Deemed Current Connection
Garnishment or Property Settlement
Are you party to a court order to enforce either your child support or alimony obligation, or to
pay part of your present or future railroad retirement benefit to a spouse or former spouse as
a part of a property settlement in a divorce or legal separation proceeding. (NOTE:
Reference to pension rights may be found in the property settlement.)?
Which situation applies?
Child Support or Alimony
Property Settlement
Criminal Offense
Have you been imprisoned or given a sentence of confinement due to a conviction for a
criminal offense?
Date of the conviction
Date of the sentence of confinement
Date the confinement began
Has the confinement ended?
Date the confinement ended
RRB Form AA-1int (12-17)

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

Deemed Current Connection
Do you have at least 25 years of railroad service and have indicated nonrailroad employment
that could break your current connection?
Were you separated from your last railroad employer involuntarily and through no fault of
your own on or after October 1, 1975?
Did you decline an offer to work in the railroad industry in the same "class or craft" as your
last railroad job?

Information About Your Military Service
Were you in active military service – such as the Army, Navy, Air Force or Marines, for the
United States?
Did you have voluntary military service during the period June 15, 1948 through December
15, 1950?
Did you have nonrailroad earnings after leaving the military service stated above and before
returning to the railroad?
Information About Your Social Security Benefits
Have you filed, or do you plan to file within the next 90 days, an application for social security
benefits?
Are you currently receiving social security benefits?
Are all or part of your social security benefits described above based on the earnings of
someone other than yourself?
Name of the person that your social security benefits are based on.
Social security number of the person that your social security benefits are based on.
Do you want this application to be used to protect the filing date for Social Security Benefits?
Information About Your Noncovered Service Pension (NCSP)
Are you receiving or expect to receive a pension or annuity or lump sum in excel of
contributions based on any work after 1956 not covered by social security or railroad
retirement?
Employer Name

Non-profit
Organization

Payment Type
Code

Employment
Begin

Employment
End

Information About Other Railroad Retirement Annuity
Have you filed within the last 30 days, or do you intend to file within the next 90 days, for an
annuity based on another person’s railroad earnings record?
Other Person's Name
Other Person's Account Number
RRB Form AA-1int (12-17)

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United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

Information About Private Pensions
Are you receiving or do you expect to receive a monthly pension or lump sum pension
payment from one or more railroad employers?
Employer Name

Pension Begin Date

Information About Medicare
Do you have a Medicare card that shows entitlement to Medicare medical insurance (Part
B)?
Have you filed for Part B within the last three months?
Do you wish to enroll in Part B?
Are you currently covered by an Employer Group Health Plan (EGHP) based on your own or
your spouse's current employment?
Receiving Your Payments
Choose how you want to receive your payments.
Routing Transit Number
Account Number
Account Type
Financial Institution Name

RRB Form AA-1int (12-17)

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