SSA-671

Railroad Employment Questionnaire

Download and Print the SSA-671

NAME OF PERSON ON WHOSE RECORD SOCIAL SECURITY BENEFITS ARE CLAIMED
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, 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 - R.R.B. CLAIM NUMBER

5. HAS ANY SURVIVOR OF THE DECEASED EVER RECEIVED A LUMP-SUM OR RESIDUAL PAYMENT OR A SURVIVOR'S MONTHLY ANNUITY FROM THE RAILROAD RETIREMENT BOARD?
YES - NO - (If "yes," also complete D below.)

6. 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
SOCIAL SECURITY NUMBER

2. HOW MANY MONTHS DID THE PERSON NAMED IN B(1) ABOVE WORK IN THE RAILROAD INDUSTRY AFTER 1936?

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 MONTHS AFTER1995, 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

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