Free Railroad Employment Questionnaire - Federal

SOCIAL SECURITY ADMINISTRATION

TOE 420

Form Approved OMB No. 0960-0078

RAILROAD EMPLOYMENT QUESTIONNAIRE
NAME OF PERSON ON WHOSE RECORD SOCIAL SECURITY BENEFITS ARE CLAIMED

DATE

SOCIAL SECURITY NUMBER

A. To be completed whenever the deceased worked the railroad industry on or after January 1937.
1. HOW MANY MONTHS DID THE DECEASED WORK IN THE RAILROAD INDUSTRY AFTER 1936? 2. HOW MANY MONTHS DID THE DECEASED WORK IN THE RAILROAD INDUSTRY BEFORE 1937? (IF NONE, ENTER "NONE") 3. DID THE DECEASED WORK IN THE RAILROAD INDUSTRY DURING THE LAST 18 MONTHS? YES NO

(if "yes" also complete C below.) 4. IF THE DECEASED'S RAILROAD SERVICE TOTALS AT LEAST 120 MONTHS, OR 60 MONTHS AFTER1995, DID THE DECEASED EVER FILED A CLAIM FOR A DISABILITY OR RETIREMENT ANNUITY
WITH THE RAILROAD RETIREMENT BOARD?
YES NO R.R.B. CLAIM NUMBER


IF "yes", enter the R.R.B. Claim Number 5. HAS ANY SURVIVOR OF THE DECEASED EVER RECEIVED A LUMP-SUM 6. OR RESIDUAL PAYMENT OR A SURVIVOR'S MONTHLY ANNUITY FROM THE RAILROAD RETIREMENT BOARD? YES NO (If "yes," also complete D below.) IF THE DECEASED EVER FILED AN APPLICATION FOR SOCIAL SECURITY BENEFITS DID THE DECEASED WORK IN THE RAILROAD INDUSTRY AT ANY TIME AFTER FILING FOR SOCIAL SECURITY BENEFITS? YES NO (If "yes," also complete C below.)

B. To be completed whenever a claim for Social Security benefits is filed and the claimant or claimant's spouse worked in the railroad industry on or after January 1, 1937.
1. NAME OF PERSON HAVING RAILROAD EMPLOYMENT 2. HOW MANY MONTHS DID THE PERSON NAMED 3. IN B(1) ABOVE WORK IN THE RAILROAD INDUSTRY AFTER 1936? SOCIAL SECURITY NUMBER 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 MONTHS AFTER1995, DID THE R.R.B. CLAIM NUMBER
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

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

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

C. To be completed if item A(3) or A(6) or B(4) or B(6) is checked "yes."
NAME OF RAILROAD EMPLOYER FROM TO

WORK LOCATION

DEPARTMENT AND OCCUPATION

D. To be completed 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, 5. parent, child, etc.)


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?
Form SSA-671 (03-2005) EF (03-2005) Destroy Prior Editions

YES

NO


Check here and use reverse for additional remarks.

PRIVACY ACT/PAPERWORK ACT NOTICE: Your response to this request is voluntary; however, failure to provide all or any of the information requested may, affect the final decision on your claim. The information requested on this form is authorized by sections 205(i) and 205(o) of the Social Security Act. The information you furnish will enable the Social Security Administration to insure proper credit is given for railroad industry employment and to facilitate any required coordination with the Railroad Retirement Board.

Paperwork Reduction Act Statement - 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 THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213. You may send comments on our time estimate above to: SSA, 1338 Annex Building, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.
REMARKS