Form AA-12 (01-19) 

NOTICE OF DEATH AND

REQUEST FOR

SERVICE NEEDED FOR ELIGIBILITY

Section 1 – Identifying Information

1. Social Security No.

2. Railroad Name and Address

Facsimile Number: 

3. Name of Deceased Employee

4. BA No. 5. Payroll Number 6. Date Last Worked

or Paid for Time Lost

7. Date of Birth 8. Date of Death 9. Date Released

Paperwork Reduction Act Notice

The Railroad Retirement Board's (RRB) authority for requesting this information is Section 7(b)(6) of the Railroad Retirement Act (RRA) (45 U.S.C. 231f(b)(6)). The information requested is used by the RRB to determine a person’s eligibility for a survivor benefit 

under Section 2 of the RRA (45 U.S.C. Sec. 231a). 

We estimate this form takes an average of 5 minutes per response, including the time for reviewing the instructions, getting the 

needed data, and reviewing the completed form. Federal agencies may not conduct or sponsor, and respondents are not required to 

respond to, a collection of information unless it displays a valid OMB number. If you wish, send any comments regarding the 

accuracy of our estimate or any other aspect of this form, including suggestions for reducing the completion time, to the Associate 

Chief Information Officer for Policy and Compliance, Railroad Retirement Board, 844 North Rush Street, Chicago, IL 60611-1275. 

Section 2 - Employer Instructions

The survivor(s) of the deceased employee has filed for benefits under the Railroad Retirement Act (RRA). The applicant provided 

the information shown in Items 6 and 8. Verification of the lag service is required for eligibility to the survivor benefit.

• Complete Item 10 below only if the date in Item 6 differs from the date on your records.

• Always complete Items 11 and 13.

• Fax this form to (312) 751-7129 or mail it to the U.S. Railroad Retirement Board, Retirement and Survivor Benefits Division

– Survivor Initial Section, 844 North Rush Street, Chicago IL 60611-1275, within 10 days of the date released by the

RRB. The survivor cannot be awarded an annuity until we receive this information.

IMPORTANT NOTE: This employee’s service months and compensation must also be included on your Form BA-3, Annual 

Report of Creditable Compensation. Do not report service months after the date of death. If you have any questions, refer to 

the ‘‘Reporting Instructions to Employers’’ or telephone the Quality Reporting Service Center at (312) 751-4992.

10. Date Employee Last Worked or Paid for Time Lost on Your Records 

Month Day Year

11. Indicate with an “X,” months the employee had service. The “Current Year” refers to the year shown in Item 6. “Prior Year” is

the year before. If this form will be submitted before your annual report for the prior year, complete items about the prior year as

well. Do not report service months after the date in Item 8.

J F M A M J J A S O N D TOTAL MONTHS

Current Year

Prior Year

12. REMARKS

Section 3 - Employer Certification

13. I understand that civil and criminal penalties can be imposed against me for false or fraudulent statements or for withholding

information to misrepresent a fact material to determining a right to payment under the Railroad Retirement Act. I certify that, to

the best of my knowledge, the information which I have given is true, complete, and correct.

Signature of Certifying Officer Date

Title of Certifying Officer Telephone No.

( )

Facsimile No.

( )

E-Mail Address

UNITED STATES OF AMERICA

RAILROAD RETIREMENT BOARD

FORM APPROVED

OMB NO. 3220-0005