Railroad Employment Questionnaire

Form Approved
OMB No. 0960-0078

TOE 420

SOCIAL SECURITY ADMINISTRATION

RAILROAD EMPLOYMENT QUESTIONNAIRE

SOCIAL SECURITY NUMBER

A. Complete whenever the deceased worked for the railroad industry on or after January 1937.
1. HOW MANY MONTHS DID THE
2. HOW MANY MONTHS DID THE
DECEASED WORK FOR THE
DECEASED WORK FOR THE
RAILROAD INDUSTRY AFTER 1936?
RAILROAD INDUSTRY BEFORE
1937? (IF NONE, ENTER "NONE")

3. DID THE DECEASED WORK IN THE
RAILROAD INDUSTRY DURING THE
LAST 18 MONTHS?
Yes

No

4. IF THE DECEASED'S RAILROAD SERVICE TOTALS AT LEAST 120 MONTHS, R.R.B. CLAIM NUMBER
OR 60 MONTHS AFTER 1995, HAD THE DECEASED EVER FILED A CLAIM
FOR A DISABILITY OR RETIREMENT ANNUITY WITH THE RAILROAD
RETIREMENT BOARD?
Yes

No

IF "yes", enter the R.R.B. Claim Number

5. HAS ANY SURVIVOR OF THE DECEASED EVER
6. IF THE DECEASED EVER FILED AN APPLICATION FOR
RECEIVED A LUMP-SUM OR RESIDUAL PAYMENT OR A
SOCIAL SECURITY BENEFITS, DID THE DECEASED
SURVIVOR'S MONTHLY ANNUITY FROM THE RAILROAD
WORK FOR THE RAILROAD INDUSTRY AT ANY TIME
RETIREMENT BOARD?
AFTER FILING FOR SOCIAL SECURITY BENEFITS?
Yes

No

(IF "yes", also complete D below.)

Yes

No

(IF "yes", also complete C below.)

B. Complete whenever a claim for Social Security benefits is filed and the claimant or claimant's spouse worked in the railroad
industry after January 1, 1937.
1. NAME OF PERSON HAVING RAILROAD EMPLOYMENT
2. HOW MANY MONTHS DID THE
PERSON NAMED IN B(1) ABOVE
WORK IN THE RAILROAD
INDUSTRY AFTER 1936?

SOCIAL SECURITY NUMBER

3. HOW MANY MONTHS DID THE
PERSON NAMED IN B(1) ABOVE
WORK IN THE RAILROAD INDUSTRY
BEFORE 1937? (if none, enter "none.")

4. DID THE PERSON NAMED IN B(1)
ABOVE WORK IN THE RAILROAD
INDUSTRY DURING THE LAST 18
MONTHS?
Yes
No
(IF "yes", also complete C below.)

5. IF THE RAILROAD SERVICE TOTALS AT LEAST 120 MONTHS, OR 60
R.R.B. CLAIM NUMBER
MONTHS AFTER 1995, DID THE PERSON NAMED ABOVE EVER FILE A
CLAIM FOR A DISABILITY OR RETIREMENT ANNUITY WITH THE RAILROAD
RETIREMENT BOARD?
Yes

No

(IF "yes", enter the R.R.B. Claim Number.)

6. DID THE PERSON NAMED IN B(1) ABOVE RECEIVE ANY RAILROAD
SICKNESS BENEFITS OR ANY RAILROAD UNEMPLOYMENT BENEFITS
DURING THE LAST 18 MONTHS?

Yes

No

(IF "yes", also complete C below.)

C. Complete if item A(3) or A(6) or B(4) or B(6) is checked "yes."
NAME OF RAILROAD EMPLOYER

WORK LOCATION

Form SSA-671 (06-2015) UF (06-2015)
Destroy Prior Editions

FROM

DEPARTMENT AND OCCUPATION

TO

D. Complete when the claimant for Social Security Benefits has received a lump-sum from the R.R.B. or has received or is
receiving a monthly R.R.B. annuity based on another individual's railroad employment.
1. NAME OF SOCIAL SECURITY CLAIMANT- R.R.B. ANNUITANT
2. R.R.B CLAIM NUMBER

3. NAME AND SOCIAL SECURITY NUMBER OF RAILROAD EMPLOYEE ON WHOSE RECORD THE R.R.B. CLAIM WAS
FILED
NAME
SOCIAL SECURITY NUMBER

4. RELATIONSHIP OF S.S. CLAIMANT TO RAILROAD
EMPLOYEE (Wife, widow, parent, child, etc.)

5. TYPE OF R.R.B. BENEFIT (Monthly, lump-sum, or residual)

6. HAS THE RAILROAD RETIREMENT BOARD NOTIFIED THE ABOVE SOCIAL
SECURITY CLAIMANT - R.R.B. ANNUITANT THAT THE AMOUNT OF THE
R.R.B. ANNUITY MAY BE AFFECTED BY ENTITLEMENT TO SOCIAL
SECURITY BENEFITS?

Paperwork Reduction Act Statement

Yes

No

See Revised Privacy Act and
PRA Statements Attached.

This information collection meets the requirements of 44 U.S.C. § 3507. as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control
number. We estimate that it will take about 5 minutes to read the instructions, gather the facts, and answer the questions. SEND
OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social
Security office through SSA's website at www.socialsecurity.gov. Offices are also listed under U. S. Government
agencies in your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may
send comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments
relating to our time estimate to this address, not the completed form.

Privacy Act Statement Railroad Employment Questionnaire
Sections 205(i) and 205(o) of the Social Security Act, as amended, authorize us to collect this information. The purpose of
collecting this information is to assist us in insuring proper credit is given for railroad industry employment and to facilitate any
required coordination with the Railroad Retirement Board. Your response is voluntary. However, failure to provide this requested
information may affect the final decision on your claim.
We rarely use the information provided on this form for any purpose other than for what we have stated above. However, in
accordance with 5 U.S.C. § 552a(b) of the Privacy Act, we may disclose the information provided on this form in accordance with
approved routine uses, which include but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits and coverage;
2. To comply with Federal laws requiring the release of information from Social Security records (e.g., to the Government
Accountability Office and Department of Veterans' Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level;
and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity of Social Security programs.
We may also use the information you provide in Computer Matching programs. Matching programs compare our records with
records kept by other Federal, State, or local government agencies. Information from these matching programs can be used to
establish or verify a person's eligibility for Federally-funded and administered benefit programs and for repayment of payments or
delinquent debts under these programs.
Explanations about these and other reasons why information you provide us may be used are available in System of Record
Notice 60-0089 (Claims Folders Systems). The notice, additional information regarding this form, and information regarding our
programs and systems are available on-line at www.socialsecurity.gov or at your local Social Security office.
Form SSA-671 (06-2015) UF (06-2015)