Form Approved Railroad Retirement Board O.M.B. No I I I

Transcription

1 United States of America Form Approved Railroad Retirement Board O.M.B. No lnstructions on nternet Application for Lump-Sum Officially Filed Do Not Write in This Space Office Numer Approved Death Payment and l Annuities Unpaid at Death, Apicaon m e, Date Coded Coded y General lnstructions Employee densmon Before you complete this application, e sure to read the ooklet RB-21, Lump-Sum Death Payment, Residual LumpSum, and Annuities Unpaid at Death, which explains information you will need to answer many of the questions in this application. Please e sure to read the important notices on the inside covers of the RB-21 ooklet. Type or print legily in ink. f you need more space than is provided to answer a question, use Section 8, Remarks, for this purpose. f you do not know the answer to a question, print "Unknown" in the space provided for the answer. When entering dates, always use numers. Also, e sure there is one numer in each ox. For example, you would enter June 6,2008 as: Some items in this application will not apply to you so you will not need to answer them. Based on your answer to a question, you may e told to skip to another item numer, or even another section. Follow the instructions that tell you to "Go to" another item. These are designed to save you time and help you move through the application form quickly, filling in only necessary information. f no "Go to" instructions are given, answer the next item in order. Do not skip any items unless directed to do so. f you are completing this application on ehalf of someone else, you must answer each question as it applies to the applicant dentifying nformation MONTH 0 6 DAY 016 YEAR Check the information entered y the Railroad Retirement Board (RRB) in tems 1 through 6 for accuracy. f the information is correct, go to tem 7. f the information is not correct, cross out the incorrect information and enter the correct information aove it. f the information is missing, fill it in. 1 Employee's Name 2 Employee's Social Security Numer 3 Employee's Railroad Retirement Claim Numer (include Prefix) Applicant dentification 4 Applicant's Name NOTE: f representative of funeral home, enter funeral home's name, representative's name, and representative's title. 5a Mailing Address NOTE: f representative of funeral home, enter funeral home address. 5 City and State 5 c ZP Code 5d County 6 Daytime Telephone Numer (include area code) 7 Applicant's social security numer. f none, enter "NONE." NOTE: Do not complete if you are the funeral home director. Form AA-21 (1 1-08) Destroy Prior Editions

2 nformation Aout The Employee f a railroad retirement survivor enefit was ~reviously received y someone. - go - to Section 5; otherwise go - to ltem 8. Birth Date 8 Enter the employee's date of irth. Day Residence 9 Enter the state (or country if other than United States) which was the employee's permanent home at the time of death. Please read the chapter, "Credit for Military Service," in the RB-21 ooklet to find out how active military service is determined. 110 Enter an " X in the appropriate ox: a Yes Go to Note and tem P- The employee was in active military service after Septemer No Gotolternl3 (' Note: f answered 'Yks, " and proof of the employee's military service is not already in ', our file, you may e requested to provide it We will notify you /icproof is needed. 11 Enter an 'X" in the appropriate ox: O Yes Go to ltem 2 The employee had voluntary military service during the period June 15,1948, through Decemer 15, No Go to tem 3 Disaility Recent employ me^ 12 Enter an " X in the appropriate ox: The employee had nonrailroad earnings after leaving the military service and efore returning to the railroad. f the employee died at 62 or older, go to tem Enter an " X in the appropriate ox: The employee was unale to work at the time of death ecause of an illness or accident which occurred at least five months efore death. Yes a No A a Yes a No 14 Regardless of whether the employee was retired at death, enter the name and address of each railroad or non-railroad employer for whom the employee performed any part-time or full-time work during the last three years. Enter the name and address of the most recent employer in 14a, the second in 14, and so on. Enter the date each jo egan and ended. f you need additional space, continue in Section 8. a Name Address City, State, and ZP Code Name and Address of Employer Benan Name Address City, State, and ZP Code Began c Name Began Address City.State, and ZP Code 15 Enter an 'X" in the appropriate ox: )Pn The employee was self-employed during any of the last three calendar years. Yes - Go to ltem 6 O No - Go to ltem 8 16 Enter an " X in the appropriate ox: O Yes - Go to ltem 7 The employee's net earnings from self-employment were more than $400 in any of the last three calendar years. No - Go to ltem 8 Form AA-21 (1 1-08) Page 2

3 Self- Employment (Continued) Railroad Employment 17 Enter an "X" in the appropriate ox(es) to show the year This year or years in which the employee's net earnings from - O Last year self-employment were more than $400. efore last 18 Enter an "X" in the appropriate ox: The employee was alive on Octoer 1, 1981, Yes Go to Note and ltem 19 - AND had at least 25 years of railroad service. a No Go toltem 21 (~ote: Please read the chapter, "Requirements the Employee Must Have Met," in the RB-21 ooklet to find out what special conditions may apply if the employee \ was alive on Octoer, 1981, and had at least 25 years of railroad service. 19 Enter an " X in the appropriate ox: The employee "involuntarily and without fault": stopped working for his or her last railroad, employer on or after Octoer, 1975, or - O was on furlouah. leave of asence status. or asent ecause of inrury on Octoer, 1975, and was never called ack to work for that employer. --J Yes Go to ltem 20 O No Go to ltem Enter an "X" in the appropriate ox: The employee declined an offer from a railroad employer - Yes Go to ltem 21 to return to a jo in the same "class or craft" as his or her O No Go to Note and ltem 21 last railroad jo. Emp]o~ee's 21 Enter an "X" in the appropriate ox: Mamages Was the employee ever married? O Yes Go to ltem 22 O No Go to Section 5 22 Enter the requested information for each of the employee's marriages. Enter the most recent marriage in 22a, the second most recent in 22, and so on. f the employee was married only once, enter the information in 22a, and go to ltem 23. a Name of Employee's Wife or Husand (if wife, include maiden name) Date Manied City and State Married (Country, if other than U.S.) How Marriage Answer if Marriage for Reason Other than Employee's Death Date Mam'age City and State Marriage (Countrv, if other 1 Day =T: Day 23 Enter an 'X' in the appropriate ox: At least one of the employee's marriages lasted for ten years - O Yes Go to Note and ltem 24 and ended in divorce. O No Go to Section 4 ( Note: f more than one marriage fits this description, use Section 8 to answer tems for each additional marriage. Page 3 Form AA-21 (1 1-08)

4 Employee's 24 Enter an 'X" in the appropriate ox: Yes - Go to ltem 25 Marriages The divorced spouse was alive in the month the employee died. - (Continued) O No - Go to Section 4 Day 25 Divorced spouse's date of irth a Enter an 'X" in the appropriate ox: Yes - Go to tem 26 The divorced spouse has remarried. a No - Go to tem 28 Divorced spouse's date of remarriage. - Day 27 a Enter an 'X" in the appropriate ox: The marriage has ended. 0 No - Go to tem a Yes - Go to ltem 27 Date the marriage ended. - Day a 1 Divorced spouse's name. c Divorced spouse's social security numer. Mailing Address - a d City and State 28e ZPCode 28f County g 1 Daytime Telephone Numer (include area code) - nformation Aout The Widow(er) Widow(er) Widow(er)'s Birthdate 29 Enter an "X" in the appropriate ox: The employee was survived y a widow(er). 30 Widow(er)'s date of irth. - a Yes - Go to ltem No - Go to Section 5 Day Widow(er)'s 31' Enter an "X" in the appropriate ox: a Yes - Go to tem 32 Disai'i" The widow(er) was age in the month the employee died. a No F Go to ltem 33 Support 32 Enter an 'X" in the appropriate ox: n the month the employee died, the widow(er) was unale to - work due to an accident or illness. 33 Enter an "X" in the appropriate ox: The widow(er) is still alive. - O Yes a NO - -- O Yes - Go to ltem 34 O Vo - Go to Section 5 34 Enter an "X" in the appropriate ox: Yes - Go to ltem 39 The employee and the widow(er) were living together - when the employee died. 0 No - Go to ltem Enter the date the widow(er) and the employee stopped living together. - Day 36 Enter the reason(s) the widow(er) and the employee stopped living together... Form AA-21 (1 1-08) Page 4

5 Support (Continued; ' 37 Enter an 'X" in the appropriate ox: The employee was making regular contriutions to the Yes Go to tem 39 widow(er)'s support when the employee died. (Consider the No Go to ltem 38 following as contriutions to support: money, food, clothes, paying ills, providing rent-free housing.) 38 Enter an 'X' in the appropriate ox: The employee was under a court order to contriute to the widaw(er)'s support. (Note: Answer 'Yes" if there was a court order, even if the employee was not oeying it.) Yes O No Nameat Birth 39 Enter an " X in the appropriate ox: am the employee's widow(er). Yes Go to ltem 40 No Go to Section 5 40 Enter your name at irth. Widow(er)'s Marriages 41 Enter an " X in the appropriate ox: am now, or was previously, married to someone other than the employee. Yes Go to ltem 42 No Go to Section 5 42 Enter the requested information for each of your marriages to someone other than the employee. Enter your spouse's name at irth and social security numer (SSN). f the SSN is unknown, provide the date and place of irth of the spouse and the name at irth of oth parents of the spouse in Section 8. Enter the most recent marriage in 42a the second most recent in 42, and so on., a Spouse's Name Social Security Numer Date Married City and State Manied (Country, if other than U.S.) How Marriage (check one) Date Marriage City and State Marriage (Country, if other than U.S.) Day Spouse's Name D Spouse's Death a Divorce D Annulment Day Social Security Numer Date Married City & State Married (Country, if other than U.S.) How Marriage (check one) Date Marriage City & State Marriage (Country, if other than US.) Day c Spouse's Name D Spouse's Death lvorce a D' a Annulment Day Social Security Numer Date Married Day City & State Married (Country, if other than U.S.) How Marriage (check one) D Spouse's Death lvorce a D' a Annulment Date Marriage Day City & State Marriage (Country, if other than U.S.) Page 5 Form AA-21 (1 1-08)

6 nformation Aout the Employee's Family Child's Annuity 43 Enter an 'X' in the appropriate ox: Yes - Go to ltem 44 There is a "child," as defined in Section, who may a No - Go to ltem 45 e eligile for an annuity. ( N i i instances) grandchild of the deceased employee who, in the month the employee died, was: UNDER age 18, or Age AND attending high school full time, or ANYAGE as long as the "child was totally and permanently disaled BEFORE the child otained age 22. For a complete explanation of the circumstances in which a "child may e eligile for 44 Provide the information requested elow for the child(ren) referred to in ltem 43. a c Child's Full Name Child's Full Name Child's Full Name Legal Relationship (Check One) 0 Natural 0 Stepchild 0 Legally Adopted 0 Equitaly Adopted 0 Deemed a Grandchild a Stepgrandchild Legal Relationship (Check One) a Natural a Stepchild a Legally Adopted a Equitaly Adopted a Deemed 0 Grandchild a Stepgrandchild Legal Relationship (Check One) Natural Stepchild Legally Adopted Equitaly Adopted Deemed Grandchild a Stepgrandchild Address Address and Telephone Numer Telephone Numer (include area code) Address Address and Telephone Numer Telephone Numer (include area code) Address Address and Telephone Numer Telephone Numer (include area code) 45 Enter an "X" in the appropriate ox: Yes - Go to ltem 48 The deceased employee was female. a No - Go to tem Enter an " X in the appropriate ox: A child of the employee is expected to e orn. No - Go to tem 48 a Yes - Go to ltem Enter month and year child is expected. Parent's Annuity 48 Enter an "X" in the appropriate ox: The employee was survived y a parent. a No - Go to tem 51 a Yes - Go to ltem Enter an 'X" in the appropriate ox: The parent was dependent on the employee for one-half support. Form AA-21-08) Page 6 Yes - Go to ltem 50 No - Go to ltem 51

7 Parent's Annuity 50 Enter the requested information for each dependent parent of the employee. a Name of Parent Date of Birth Address and Telephone Numer Name of Parent Address and Telephone Numer nformation Aout Applicant Children 51 Enter an " X in the appropriate ox: am the employee's widow(er) and was living with the a No - Go to ltem 52 employee when the employee died. a Yes - Go tosection 7 52 Enter an " X in the appropriate ox: am completing this application as a representative of a a No - Go to ltem 53 funeral home. 53 Enter an "X" in the appropriate ox: am the employee's natural child, legally adopted child, equitaly adopted child, deemed child, parent, grandchild, rother, sister, half-rother or half-sister. Name of Child (f none, enter "NONE) Natural Legally Adopted Equitaly Adopted Deemed a Yes - Go tosection 7 a Yes - Go to ltem 54 No - Go to Section 6 54 Enter the requested information for any surviving child(ren) of the employee (except stepchildren) not listed in ltem Legal (Check One) a Natural a Legally Adopted Equitaly Adopted Deemed Natural Legally Adopted a Equitaly Adopted 0 Deemed - Address and Telephone Numer (include area code) Grand- Children Note: f any child is listed aove, go to Section Enter the requested information aout any surviving grandchild(ren) of the employee not identified in ltem 44 (except a stepgrandchild) no matter how old they are, what their marital status is, and regardless of whether the employee was supporting them. (f none. enter NONE) of Parents Name of Grandchild Address and Telephone Numer (include area mde) Name at Birth Father Mother Father Page 7 Form AA-21 (1 1-08)

8 Grand- Children (Continued) Name of Grandchild (f none, enter "NONE) Address and Telephone Numer (include area code) Father Name at Birth of Parents Mother d Father Mother Note: f any child is listed in ltem 55, go to Section 6. Brothers and Sisters 56 Enter the employee's surviving rothers, sisters, half rothers and half sisters. Do Not include steprothers or stepsisters. f you need additional space, continue in Section 8. Name (f none, enter "NONE) Address and Telephone Numer (include area code) a See Section 11 for additional instructions efore answering questions in Section 6. Funeral Home Expenses AEnmW d Responsiih' 57 Enter the total amount of funeral home expenses. $ 58 Enter the amount of funeral home expenses paid with your own money. - $ None (f none, check ox.) 59 Enter the amount of funeral home expenses paid with the employee's money. $ O None (f none, check ox.) 60 Enter the amount of funeral home expenses paid with any other person's money. - $ O None (f none, check ox.) 61 Enter the amount of funeral home expenses which are O None still not paid. (f none, check ox.) f "None," go to tem 66 - The RRB considers that a person has assumed responsiility for unpaid funeral home expenses if either the person has paid some portion of the total funeral home expenses or there is an agreement etween the person and the funeral home aout how the expenses will e paid. 62 Enter an "X" in the appropriate ox: a Yes Go to tem 65 have assumed responsiility for the funeral home expenses which are not paid. a No Go to ltem Enter an "X" in the appropriate ox: Yes Go to tem 64 Some other person or organization has assumed responsiility for the funeral home expenses which are not paid. 0 Vo Go to ltem 66 Form AA-21 (11-08) Page 8

9 64 Enter the full name of the person or organization who assumed responsiility then go to tem 66. Name Address Address of funeral home Telephone Numer (include area code) 65 f any of the funeral home expenses are unpaid, the lump-sum death payment (or a part of the lump-sum death payment equal to the amount of the unpaid funeral home expenses) can only e paid to the funeral home. However, efore this payment can e made, you must authorize the RRB to make the payment. request the RRB to pay the lump-sum death payment to: Name of funeral home 1 Te'hone Numer (include area de) r ~ o t e f : there are unpaid funeral home expenses at more than one 7, [ funeral home, show the name, address, and telephone numer of the other funeral home(s) in Section 8. i 1 Opening and Closir of Grave 66 Enter the total amount of the cost of opening and closing the grave not included in tem $ J None (f none, check ox.) f "None." ao to ltem 70 When answering tems 67-77, consider any money you received from a life insurance policy or other death enefit as your own if you were named as the eneficiary for the policy or enefit. Also, consider money from any ank account as your own if you were one of the joint owners of the account. 67 Enter the amount of the grave opening and closing costs paid with your own money. (f none, check ox.) 68 Enter the amount of the grave opening and closing costs paid with the employee's money. (f none, check ox.) 69 Enter the amount of the grave opening and closing costs paid with any other person's money. (f none, check ox.) - $ J None - $ J None J None Burial Plot 70 Enter the total amount of the cost of the urial plot not included in tem $ J None (f none, check ox.) f "None," go to ltem Enter the amount of the urial plot cost paid with your own money. - $ J None (f none, check ox.) 72 Enter the amount of the urial plot cost paid with the employee's money. - $ J None (f none, check ox.) 73 Enter the amount of the urial plot cost paid with any other person's money. - $ J None (f none, check ox.) Page 9 Form AA-21 (1 1-08)

10 Other Burial Expenses Other Federal Allowances 75 Enter the amount of other urial expenses paid with your own money. (f none, check ox.) 74 Enter the amount of other urial expenses not included in ltem 57. $ Q None (f none, check ox.) f "None," go to tem Enter the amount of other urial expenses paid with the employee's money. (f none, check ox.) 77 Enter the amount of other urial expenses paid with any other person's money. (f none, check ox.) $ $ $ 78 Enter an "X" in the appropriate ox: An application for a urial allowance has een, or will e, a Yes Go to ltem 79 filed with the Department of Veterans Affairs or other a No Go to tem 80 Federal agency. 79 Enter the requested information aout who the application for a urial allowance has een, or will e, filed with. Q None Q None Q None Agency Name of Person Filing with Agency Amount a Department of Veteran Affairs a Other Federal Agency (Specify) $ Reimursement 80 f you did not pay any of the urial expenses, go to ltem 82. When answering tems 80 and 81 DO NOT consider any money you received from a life insurance policy or other death enefit if you received the money ecause you were named eneficiary for the policy or enefit. DO NOT consider any money from any ank account if you were one of the joint owners of the account. Also, DO NOT consider any money, goods, or property that you inherited from the employee under the provisions of a valid will or applicale state law Enter an " X in the appropriate ox: have received, or will receive, money or property!j Yes Go to tem 81 (real estate or other goods) to pay me ack for the a No Gotoltem82 urial expenses paid. 81 Enter the requested information for each source of payment to you. 1 Source of Money or Property Date Received or Expected Amount or Value Estate 82 Enter an " X in the appropriate ox: A court appointed administrator or executor has een!j Yes Go to ltem 83 appointed. (Answer "No" if someone has een named in!j No Go to tem 84 the employee's will only.) Form AA-21 (11-08) Page 10

11 Estate (Continue d) 83 Enter the requested information aout the administrator or executor. a Name (f applicant, enter "SELF" and go to ltem 84) Address c Telephone Numer (include area code) Other Payers of Burial Expenses 84 Answer only if any other person or organization paid any of the urial expenses Enter the requested information for each source who paid expenses. Name, Address, and Telephone Numer of Person or Organization Type of Burial Expenses (Check One) Q Funeral Home Q Grave OpeninglClosing Q Burial Plot a Other a Funeral Home a Grave OpeninglClosing Q Bulial Plot a Other 0 Funeral Home Grave OpeninglClosing a Burial Plot Q Other Direct Deposit Do not complete this section if your account is at a foreign ank. Funeral Home Q Grave OpeninglClosing Q Burial Plot Q Other $ $ $ $ Amount Direct Deposit Benefits are normally paid y Direct Deposit to your ank, savings and loan, credit union, or other financial institution. To provide the information we need to correctly deposit your payments, attach a voided personal check and go to Section 8, or call your financial institution for the information you need to complete tems f you do not have a ank account, or receiving your payments y Direct Deposit would cause you a hardship, go to ltem Print the name of your financial institution. 86 Print the telephone numer (including area code) for your financial institution. 87 Print the routing transit numer of your financial institution. 88 Print your account numer. 89 Enter an " X in the appropriate ox: Type of account for the aove account numer. 90 Check this ox if you do not have a checking or savings account, or if Direct Deposit would cause you a hardship. 0 a Checking a Savings Go to Section 8 Page 11 Form AA-21 (1 1-08)

12 Remarks Remarks 91 This section is to e used for the continuation of answers to other items. Be sure to include the item numer at the eginning of the answer you wish to continue. You may also use this section to enter any additional information that you feel may e important to include. Form AA-21 (1 1-08) Page 2

13 Certification Certification 92 1 know that if make a false or fraudulent statement in order to receive enefits from the Railroad Retirement Board, (RRB), am committing a crime which is punishale under Federal law. f receive the lump-sum death payment ecause paid the employee's urial expenses, also agree not to request or accept reimursement from another party for that part of the urial expenses for which am reimursed y the lump-sum death payment. have received the appropriate application ooklet. certify that the information gave to the RRB on this application is true to the est of my knowledge. Signature (First Name, Middle nitial, Last Name) Date 93 f this application is signed y mark ('X") in tem 92, two witnesses who know the person signing must sign elow, giving their full addresses and daytime telephone numers. 1 a Signature of Witness Address (Numer and Street) City. State, and ZP Code Daytime Telephone Numer (include area mde) Signature of Witness Address (Numer and Street) City, State, and ZP Code Daytime Telephone Numer (include area mde) Before you return your application, check to make sure that: Every question that applies to you has een answered. You have entered "unknown" in any answer space for which you were unale to answer a question. You have signed and dated the application. You have included all the needed proofs listed in the letter you received with this application. When you received your application, you should also have received a pre-addressed return envelope. f you do not have this envelope, you can use any envelope as long as it is addressed to the RRB shown on the last page of this application. No matter which envelope you use, you must put the correct postage on the envelope. Be careful to provide enough postage, ecause your application and the accompanying forms may weigh more than a standard letter. The U.S. Postal Sewice will not deliver your application unless it has the correct postage. Make one final check efore you seal the envelope to ensure that the following are enclosed: Needed proofs The application itself Additional forms you were asked to complete i Note: A receipt for your application will e sent to you after the RRB receives your completed and signed application. When you receive the receipt, you will know that the RRB has received your application and has started the work needed to determine if you are entitled to enefits. f you do not receive your receipt within a month after you filed this application, please contact us so we can find out what is causing the delay. Page 13 Form AA-21 (1 1-08)

14 This section contains m&e detailed instructions or explanations for a few of the items on the application form. Whenever the instructions on the Form AA-21 refer you to Section 11 you should read this section for the particular question or section efore you complete that part of the application. This section can e detached from the Form AA-21 packet efore the application is returned to the Railroad Retirement Board (RRB). The RRB may e ale to pay an annuity to a child of a deceased railroad employee if the child meets certain requirements. When we use the word "child" we are including all of the following categories of children: Natural child. Stepchild. Legally adopted child. Equitaly adopted child (that is, the employee intended to adopt the child ut a legal adoption was not complete efore the employee died). Deemed child (that is, a child who is orn during an invalid marriage). Grandchild. Stepgrandchild. n order to e considered for an annuity, the child must e unmarried. n addition, the child must e: under age 18; or age 18 or older and ecame disaled efore age 22 and the disaility is not expected to ever go away; or age and is attending high school full time. f the child is the employee's stepchild, the employee must have een providing at least one-half support. f the child is the employee's grandchild or stepgrandchild, the employee must have een providing at least one-half of the child's support and either the child's own parents were dead or disaled or the child was legally adopted y the employee's widow or widower. Even if there are no children who meet all these requirements right now, a child's annuity may e ale to e paid if any child met all the requirements in the month the employee died or later or, if the employee died more than six months ago, if any child met these requirements anytime in the last six months. f there is any child who meets these requirements, put an " X in the "YES" ox. n addition, you, some other adult acting for the child, or the child should contact the RRB as soon as possile and request information aout childrens' annuities. Section 6 (tems 57-84) Section 6: nformation Aout Burial Expenses requires various information aout the types of urial expenses which have resulted from the employee's death and aout the people who paid these expenses and the money which was used to pay the expenses. Please refer to the following definitions when completing tems!3-84. Burial Expenses Burial expenses include any expenses which arose in connection with the urial or cremation of the employee's ody. These include the urial plot, casket, clothing, cremation, death certificates, emalming, flowers, hearse and car for funeral procession, minister, monument, newspaper notice, niche, opening and closing of grave, permits, perpetual care of grave, preparation of ody for urial, religious services, telegrams, telephone calls, transportation of the ody, traveling expenses of the person escorting the corpse or completing urial arrangements, and so on. Funeral Expenses Funeral expenses include any of the aove urial expenses if the expense is incurred y or through the funeral home. n other words, any urial expense which is included in the funeral home's charges is considered a funeral expense. Burial Plot Cost The cost of the urial plot is the value of the plot at the time the employee is uried, even if the plot was purchased efore the employee's death. f the plot in which the employee is uried is part of a multiplot plot, only the portion of the value of the plot which corresponds to the portion of the plot in which the employee is uried is considered the urial plot cost. Form AA-21 (1 1-08) Page 14 Continued to Page 15

15 Continued from Page 14 Other Burial Expenses Any urial expense which is not included in the funeral home's charges, is not the cost of opening or closing of the grave and is not the urial plot cost can e included in the total other urial expenses. Your Own Money You should consider that you paid expenses with your own money if the money used to pay the expenses was your own personal funds, money in a ank account if it was a joint account owned y you and the employee, money from an insurance policy if you were the eneficiary of the policy, or death enefits from a fraternal association, union or employer if you were named eneficiary of the enefits. f you are applying as the representative of an institution, organization, or association you should treat the money paid y the institution, organization, or association that you are representing as your own money. The Employee's Money No matter who makes the actual payment, consider that urial expenses were paid with the employee's money if the money used to make the payment was: cash which the employee had at death, money which was in a ank account which was owned only y the employee; money otained y selling any of the employee's property; unpaid wages which an employer was holding; money from a trust fund or money from an insurance policy which the employee owned, if there was no eneficiary or if all the eneficiaries died efore the employee; any payment made to a funeral home y the employee prior to the employee's death as part of a pre-need urial plan. Other Person's Money Any portion of the urial expenses which has een paid using funds other than those considered to e your own money or the employee's money should e shown as expenses paid with any other person's money. The term "person" can e applied to an individual, partnership, organization, fraternal association or government unit. Reimursement The lump-sum death payment may e paid as a reimursement to the person(s) who paid the employee's urial expenses. An individual who receives the lump-sum death payment on this asis agrees not to request or accept reimursement from another party for that part of the urial expenses reimursed y the lump-sum death payment. You must sumit proof of payment of the urial expenses. Part V of the ooklet RB-21, Lump-Sum Death Payment, Residual Lump-Sum, and Annuities Unpaid at Death, explains what proof is acceptale. f there are certain expenses such as flowers, telegrams, phone calls or payments for religious ceremony for which you did not receive a receipt, use Section 8 to list the expenses and the amount of each expense..*- Note: f you are applying on ehalf of a medical school, dental school, or anatomical oard, use Section 8 to show the date of final disposition of the employee's ody (that is, the date when the ody was uried or when the ashes from the cremation are scattered or otherwise put to rest). f 7 there has een no final disposition of the ody, indicate that in Section 8. ) Page 1 5 Form AA-21 (1 1-08)