AA-1cert (xx-xx) ( Application Summary and Certification

PROPOSED (ALL POSSIBLE)

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0002

APPLICATION SUMMARY and CERTIFICATION FOR (AN EMPLOYEE ANNUITY/
A DISABLED EMPLOYEE ANNUITY/MEDICARE)
RRB Claim Number
Name
Social Security Number
The following information was either supplied by or verified by you in support of your
application for (an Employee Annuity/a Disabled Employee Annuity/Medicare) under
the Railroad Retirement Act. After you have reviewed the information, make any
changes on the summary, initial the change and sign the certification on the last page.
Return the certification and all pages of the summary to the RRB.
Military Service
1

I was not in active military service.

2

I was in active military service.

Recent Employment
3

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

4

I worked for the following employers outside the railroad industry during the last
six months or since leaving the railroad industry.
(Company Name)
(Company Name)
(Company Name)

5

from 99/99/9999 to 99/99/9999
from 99/99/9999 to 99/99/9999
from 99/99/9999 to 99/99/9999

I worked for the following employers as a seasonal employee:
(Company Name)
(Company Name)
(Company Name)

6

from 99/99/9999 to 99/99/9999
from 99/99/9999 to 99/99/9999
from 99/99/9999 to 99/99/9999

I was self-employed during the last six months.

Railroad Employment
7

You have a current connection with the railroad industry.

RRB Form AA-1cert (xx-xx)

92948 74790 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0002

8

A current connection with the railroad industry is “deemed” because you:
1 Have at least 25 years of railroad service, and
2 “Involuntarily and without fault” stopped working for the railroad on or after
October 1, 1975 and was never called back to work for the railroad employer,
and
3 Did not decline an offer from a railroad employer to return to a job in the same
“class or craft” as the last railroad job.

9

You do not have a current connection with the railroad industry.

10

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

Name and Address
Daytime Telephone Number
Alternate Telephone Number
Date of Birth
Type of Application Filed

(Employee Annuity /Disabled Employee Annuity/
Medicare)

11

I am applying for a benefit based on my age and railroad service.

12

I am applying for a benefit based on being disabled.

13

You have requested that any payment due you be sent to the following bank
account:
Bank Name
Routing Number
Account Number
Account Type

14

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.

15

Any payment due you will be sent to the address shown above.

RRB Form AA-1cert (xx-xx)

92948 74790 22000 06051 32704

Page 2

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0002

Marriages
16

I have never been married.

17

I am currently married or separated.

18

I was previously married.

Family
19

I have a child or children who are unmarried and under age 18.

20

I have a child or children who are unmarried and age 18 through 19 and attending
elementary or secondary school full-time.

21

I have a child or children who are unmarried and age 18 or older with a continuing
disability that began before age 22 and prevents any type of employment.

22

I do not have unmarried qualifying children.

23 I am expecting a newborn. Expected delivery date: MMDDYYYY.
24 I am not expecting a newborn.
Other Government Benefits
25

I am currently receiving a social security benefit.

26

I have filed or plan to file in the next three months for social security benefits on
my own account.

27

I have filed or plan to file in the next three months for social security benefits on
the account of:
Name
Social Security Number

28

I have not filed nor do I plan to file in the next three months for social security
benefits on any account number.

29

I have not filed nor do I plan to file in the next three months for social security
benefits on an additional account number.

30

I am not receiving a social security benefit.

RRB Form AA-1cert (xx-xx)

92948 74790 22000 06051 32704

Page 3

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0002

31

In the past month I have filed or plan to file in the next three months for railroad
retirement benefits based on the account of:
Name
Claim Number

32

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.

33

I am currently receiving a railroad retirement annuity on another account number.

34

I am receiving or expect to receive a pension or I received or expect to receive a
lump-sum payment instead of a monthly pension based on my earnings after 1956
from an employer not covered by social security or railroad retirement.

35

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
36

I am receiving a railroad pension from ______________.

37

I received a lump-sum payment from _________________.

38

I expect to receive
________________.

39

I am not receiving nor do I expect to receive a pension or lump-sum payment from
a current or former railroad employer.

40

I have received or I expect to receive worker’s compensation benefits.

41

I have not received nor do I expect to receive worker’s compensation benefits.

42

I have received or I expect to receive disability benefits under a Federal, state or
local government plan or law.

43

I have not received nor do I expect to receive disability benefits under a Federal,
state or local government plan or law.

a

railroad

pension

or

lump-sum

payment

from

Miscellaneous Information
RRB Form AA-1cert (xx-xx)

92948 74790 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0002

44

The RRB has not been furnished with a court order to enforce my child support or
alimony obligation.

45

The RRB has been furnished with a court order to enforce my child support or
alimony obligation.

46

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.

47

The RRB has 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.

48

I had living with me at least one of my own or my spouse’s children, who was under
age 3.

49

I have not had at least one of my own or my spouse’s children, who was under age
3, living with me.

50

I have not received nor do I expect to receive pay for time lost from my last railroad
employer.

51

I have received pay for time lost from my last railroad employer.

52

I expect to receive pay for time lost from my last railroad employer.

53

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.

54

I have received 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.

55

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.

56

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.

57

I have filed a lawsuit or claim against the following person or company for a
personal injury where I also received sickness benefits as a result of that injury.

RRB Form AA-1cert (xx-xx)

92948 74790 22000 06051 32704

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United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0002

Name
Address
Address
58

I expect to file a lawsuit or claim against the following person or company for a
personal injury where I also received sickness benefits as a result of that injury.
Name
Address
Address

Earnings Information
59

In (prior year), my total nonrailroad earnings were (actual earnings).

60

In (prior year), my nonrailroad earnings were less than (annual exempt amount).

61

In (prior year), I earned more than (monthly exempt amount) in each month.

62

In (prior year), I earned less than (monthly exempt amount) in the following
months:
January February March April May June July August September
October November December

63

In (current year), I expect my total nonrailroad earnings will be (estimated
earnings).

64

In (current year), I expect my total nonrailroad earnings will be less than (annual
exempt amount).

65

In (current year), I expect to earn more than (monthly exempt amount) in each
month.

66

In (current year), I expect to earn less than (monthly exempt amount) in the
following months:
January February March April May June July August September
October November December

67

In (next year), I expect my total nonrailroad earnings will be (estimated earnings).

68

In (next year), I expect my total nonrailroad earnings will be less than (estimated
earnings).

RRB Form AA-1cert (xx-xx)

92948 74790 22000 06051 32704

Page 6

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0002

Criminal Offense Information
69

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.

70

Within the past 12 months I have been imprisoned or been given a sentence of
confinement due to a conviction for a criminal offense.

Beginning Dates and Filing Dates
71

You have requested your annuity begin on the earliest date permitted by law, even
if you will receive a reduced annuity.

72

You have requested your annuity begin on the earliest date permitted by law, as
long as it does not result in a reduced annuity.

73

You have selected _______________ for the beginning date of your annuity.

74

This application will protect your filing date for social security benefits.

75

I do not want this application to protect my filing date for social security benefits.

Medicare
76

You are enrolled in the Medicare Medical Insurance Plan (Part B).

77

You wish to enroll in the Medicare Medical Insurance Plan (Part B).

78

You recently applied for the Medicare Medical Insurance Plan (Part B).

79

You do not wish to enroll in the Medicare Medical Insurance Plan (Part B) at this
time.

80

My annuity will begin before I am age 63 and I am totally disabled for work.

81

You are claiming a special enrollment period based on coverage by an employer
group health plan.

82

You are claiming premium surcharge relief based on coverage by an employer
group health plan.

RRB Form AA-1cert (xx-xx)

92948 74790 22000 06051 32704

Page 7

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0002

Application for (Employee Annuity/Disabled Employee Annuity/Medicare) Certification
RR Claim Number
Name
Social Security Number
I certify that the information I have given to the Railroad Retirement Board (RRB) in
relation to 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 a summary of the information I provided. I understand
that I have an obligation to advise the RRB immediately if there are any errors in the
summary I received, and I have made and initialed any corrections on the summary
being returned to the RRB.
(Printed if application is for Employee Annuity and employee is FRA or older.)
I have received and reviewed the booklets RB-1, Age and Service Employee Annuity,
and RB-9, Events that Affect Employee and Spouse Annuities. I understand that I am
responsible for reporting events that would affect my annuity as explained in the
booklets. Failure to report any of the events listed below or other events that may affect
my annuity may result in a penalty deduction from my annuity, as well as criminal and/or
civil prosecution.
(Printed if application is for Employee Annuity and employee is under FRA.)
I have received and reviewed the booklets RB-1, Age and Service Employee Annuity,
RB-9, Events that Affect Employee and Spouse Annuities, and Form G-77a, How Work
Affects Your Railroad Retirement Benefits. I understand that I am responsible for
reporting events that would affect my annuity as explained in the booklets and form.
Failure to report any of the events listed below or other events that may affect my
annuity may result in a penalty deduction from my annuity, as well as criminal and/or
civil prosecution.
(Printed if application is for Disabled Employee Annuity.)
I have received and reviewed the booklets RB-1, Age and Service Employee Annuity,
RB-1d, Employee Disability Benefits, and RB-9, Events that Affect Employee and
Spouse Annuities. I understand that I am responsible for reporting events that would
affect my annuity as explained in the booklets. Failure to report any of the events listed
below or other events that may affect my annuity may result in a penalty deduction from
my annuity, as well as criminal and/or civil prosecution.
RRB Form AA-1cert (xx-xx)

92948 74790 22000 06051 32704

Page 8

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0002

I agree to immediately notify the RRB, if
• I return to work for a railroad or railroad labor organization, or return to work in
any capacity in the railroad industry.
• I receive a lump-sum payment or begin to receive a pension based on earnings
not covered by the Social Security Administration or the Railroad Retirement
Board.
• I file for social security benefits based on any person’s earnings record.
• Benefits I receive directly from the Social Security Administration are adjusted for
a reason other than normal cost-of-living increases.
• I am filing in advance and my last date of employment changes.
• I return to work for (print last nonrailroad employer).
• I earn over the annual earnings exempt amount.
• My expected earnings amount changes.
• I perform work, including self-employment, for a family owned, controlled or
managed business, including a business operated, managed or owned by me, 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.).
• I 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.
• I receive anything of value in lieu of salary or wages for any work that I performed.
• I begin to receive worker’s compensation or a public disability benefit.
• I receive a settlement with credit for railroad service as “pay-for-time-lost” for
months after (print date railroad employment ended).
• I receive a lump-sum payment or begin to receive a monthly pension from my
railroad employer.
• My address changes.
• My financial organization or the account number at my financial organization
changes.
• I am confined in a jail, prison, penal institution, or correctional facility due to a
conviction for a criminal offense.
• My spouse who is receiving a benefit dies or our marriage ends in divorce or
annulment.
• A qualifying child marries or leaves my custody or residence.
_________________________________
_________________________________
Signature (First Name, Middle Initial, Last Name)
Date (Month/Day/Year)
RRB Form AA-1cert (xx-xx)

92948 74790 22000 06051 32704

Page 9

United States of America
Railroad Retirement Board

Form Approved
OMB 3220-0002

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

________________________________________
Signature of Witness

_____________________________________
Signature of Witness

________________________________________
Address (Street, City, State and ZIP Code)

_____________________________________
Address (Street, City, State and ZIP Code)

(_____)__________________________________
_
Daytime Telephone Number

RRB Form AA-1cert (xx-xx)

92948 74790 22000 06051 32704

(_____)______________________________
Daytime Telephone Number

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