AA-3sum (completed Application Summary

Proposed (Completed)

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0042

APPLICATION SUMMARY FOR A SPOUSE ANNUITY
Employee’s Name
RR Claim No.
Social Security Number
Date of Birth

Jane Public
A 123-45-6789
123-45-6789
08/28/1939

The following information was either supplied by or verified by you in support of your application for
(a Spouse Annuity/a Divorced Spouse Annuity/Medicare) 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 of 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.
Applicant Information
Name and Address
Daytime Telephone Number
Alternative Telephone Number
Social Security Number
Date of Birth

John Public
215 Backstreet Market
Orlando Fl 02202
555-201-8552
555-201-8553
987-65-4321
02/20/1953

Type of Application Filed Spouse Annuity
Application Filing Date

July 25, 2018

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.
Applicant’s Marriages
You are currently married to or separated from the employee.
RRB Form AA-3sum (07-19)

8131 11920 22000 06051 32704

Page 1

Proposed (Completed)

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0042

You were not married before your marriage to the employee.
Criminal Offense Information
Within the past 12 months you have not been imprisoned or given a sentence of confinement due
to a conviction for a criminal offense.
Other Government Benefits
You have not filed nor do you plan to file in the next three months for Social Security benefits on
any account number.
You are not receiving a social security benefit.
In the past month you have not filed nor do you plan to file in the next three months for Railroad
Retirement benefits on any other account number.
You are not currently receiving a railroad retirement annuity.
You are not receiving nor do you expect to receive a pension or lump-sum payment based on your
earnings from a Federal, state or local government agency.
Earnings Information
In 2018, you expect your total earnings will be less than $45,360.
Railroad Work and NonRailroad Work
You have not worked for a railroad, railroad labor organization or other employer in the railroad
industry.
You have worked for the following employers outside the railroad industry in the six months before
you expect your annuity to begin:
Jive Records

from 04/28/1993 to 01/20/2016

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.
You do not want this application to protect your filing date for Social Security benefits.
RRB Form AA-3sum (07-19)

8131 11920 22000 06051 32704

Page 2

United States of America
Railroad Retirement Board

Proposed (Completed)

Form Approved
OMB No. 3220-0042

Your application for a Spouse Annuity has been released and will be processed as quickly as
possible. If you do not receive notification about your application by November 17, 2018 you should
contact the field office shown below.
You have received and reviewed the booklets RB-30, Spouse/Divorced Spouse Annuity, RB-9,
Events that Affect Employee and Spouse Annuities, and Form G-77a, How Work Affects Your
Railroad Retirement Benefits. It is your responsibility to report events that would affect your annuity
as explained in the booklets and form. 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 12:00 PM Wednesday.
Always Report These Changes to the RRB
• Marriage – If your marriage to the employee ends by death or divorce.
• Social Security – If you file for social security benefits based on any person’s earnings record.
• Public Pension – If you receive a lump-sum payment or begin to receive a monthly pension
based on your earnings at an agency of the Federal, state or local government.
• Earnings – If your earnings change.
• On your application you told us you expect your total earnings for 2018 to be less than $45,360.

• Railroad Work – If you go to work for a railroad or railroad labor organization or work in any
capacity in the railroad industry you.
• Employment – If you 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.).
• 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 I
performed.
• Address – If your address changes, even if your payments are sent to a financial organization.
• 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.

RRB Form AA-3sum (07-19)

8131 11920 22000 06051 32704

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United States of America
Railroad Retirement Board

Proposed (Completed)

Form Approved
OMB No. 3220-0042

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 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:
US Railroad Retirement Board
844 N Rush Street
Chicago, Illinois 60611-1275
https://www.rrb.gov

RRB Form AA-3sum (07-19)

8131 11920 22000 06051 32704

Page 4