Form SSA-671 (06-2015) UF (06-2015)
D. Complete 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.
2. R.R.B CLAIM NUMBER1. NAME OF SOCIAL SECURITY CLAIMANT- R.R.B. ANNUITANT
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, parent, child, etc.)
5. 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?
NoYes
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
OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social
Security office through SSA's website at www.socialsecurity.gov. Offices are also listed under U. S. Government
agencies in your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may
send comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments
relating to our time estimate to this address, not the completed form.
Privacy Act Statement Railroad Employment Questionnaire
Sections 205(i) and 205(o) of the Social Security Act, as amended, authorize us to collect this information. The purpose of
collecting this information is to assist us in insuring proper credit is given for railroad industry employment and to facilitate any
required coordination with the Railroad Retirement Board. Your response is voluntary. However, failure to provide this requested
information may affect the final decision on your claim.
We rarely use the information provided on this form for any purpose other than for what we have stated above. However, in
accordance with 5 U.S.C. § 552a(b) of the Privacy Act, we may disclose the information provided on this form in accordance with
approved routine uses, which include but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits and coverage;
2. To comply with Federal laws requiring the release of information from Social Security records (e.g., to the Government
Accountability Office and Department of Veterans' Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level;
and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity of Social Security programs.
We may also use the information you provide in Computer Matching programs. Matching programs compare our records with
records kept by other Federal, State, or local government agencies. Information from these matching programs can be used to
establish or verify a person's eligibility for Federally-funded and administered benefit programs and for repayment of payments or
delinquent debts under these programs.
Explanations about these and other reasons why information you provide us may be used are available in System of Record
Notice 60-0089 (Claims Folders Systems). The notice, additional information regarding this form, and information regarding our
programs and systems are available on-line at or at your local Social Security office.
