Receipt for Claim

United States of America
Railroad Retirement Board

Current (Completed)

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
RRB Form AA-1int (12-17)

Jane Doe
[email protected]
F
10/8/1945
Yes

No
PO Box 422
8618 Ligula
Chapra
IL
23456
5559876543
5551234567

Full Age
Yes
Yes

Married
No
No

No
No

Yes

1
Page 1

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

Name
David Gentry
Nicole Gentry

Relationship to Employee
Male Spouse
Child

Information About Your Railroad Work
Organization Name
Union Pacific

Employment Begin Date
08/07/1950

Employment End Date
5/30/2017

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?
Are you still self employed?
Date last self employed.

Employer Name
Cakes by Eve

No

Yes

No
06/01/2017

Employment Begin Date
01/01/2000

Employment End Date
06/01/2017

Information About Your Earnings
Earnings for 2016
Do you expect your annuity to begin before January
1, 2017?
Were your total earnings from all employment in
2016 more than $41880?
Enter your total earnings for 2016
Did you earn more than the 2016 monthly earnings
exempt amount of $ 3490 in all employment in every
month of 2016?
Indicate each month in 2016 which you did not earn
more than the monthly earnings exempt amount
from all employment.

RRB Form AA-1int (12-17)

Yes
No

JAN
APR
JUL
OCT

FEB
MAY
AUG
NOV

MAR
JUN
SEP
DEC

Page 2

United States of America
Railroad Retirement Board

Earnings for 2017
Do you expect your total earnings from all
employment in 2017 to be more than $44880?
Enter the total amount you expect to earn 2017
Do you expect to earn more than the monthly
earnings exempt amount of $3740 in employment for
hire, or to perform substantial services in selfemployment in every month 2017?
Indicate each month in 2017 which you do not
expect to earn more than the monthly earnings
exempt amount from all employment.

Earnings for 2018
Do you expect your total earnings from all
employment in 2018 to be more than $44880?
Enter the total amount that you expect to earn 2018.
Indicate each of the first four months in 2018 which
you expect to earn LESS than the 2018 monthly
earnings exempt amount of $3740.

Form Approved
OMB No. 3220-0002

No

JAN
APR
JUL
OCT

FEB
MAY
AUG
NOV

MAR
JUN
SEP
DEC

No

JAN FEB MAR APR

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.

No

Railroad Sick Pay
Did you receive or expect to receive sick pay under a No
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
RRB Form AA-1int (12-17)

Page 3

United States of America
Railroad Retirement Board

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

Form Approved
OMB No. 3220-0002

No

Information About Garnishment, Criminal Offense, and Deemed Current Connection
Garnishment or Property Settlement
Yes
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.)
Child Support or Alimony
Which situation applies?
Property Settlement
Criminal Offense
No
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
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?

RRB Form AA-1int (12-17)

No

Page 4

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

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?

Yes

No

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?

Yes
Yes
Yes

David Gentry
908-85-3542
No

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?

No

Employer Name

Employment
Begin

Non-profit
Organization

Payment Type
Code

Employment
End

Information About Other Railroad Retirement Annuity
Have you filed within the last 30 days, or do you intend No
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)

Page 5

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0002

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

No

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?

No
No
Yes
Yes

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)

Direct Deposit
09876
9864975
Savings
Citibank

Page 6