Part I requests identifying information about the worker, the worker's social insurance coverage in the other country, and the type of benefits being claimed under an Agreement. Always complete this part.

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  Item 1 - This item asks for identifying information about the worker (living or deceased) on whose record the claim is based.

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  Item 2 - This item asks for information about the worker's social security credits (coverage) as well as the last place of residence in the foreign country.

  NOTE: Specific information about all periods of foreign coverage is needed to help the foreign agency in locating the worker's records. Failure to provide accurate and complete responses to these questions may result in an incomplete record of the worker's coverage in the foreign country.

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    Sub-item 2(a) asks for information about the worker's employment or self-employment in the foreign country. Do not include any periods of coverage that are not based on work activity (see Sub-item 2(b) below). If any of the requested information is unknown, enter “unknown.”

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    2(a)(1) Dates Worked - Where the worker had two or more non-continuous periods of coverage under the foreign system (e.g., 1942-1948 and 1951-1963), list each period separately. Use the “Remarks” section (Item 19) or Form SSA-795 (Statement of Claimant or Other Persons) if more space is needed.

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    2(a)(2) Name and Address of Employer or Self-Employment Activity - Enter the business name and address for each employer or self-employment activity.

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    2(a)(3) Type of Industry or Business - Enter the type of industry or business in which the worker was engaged when the coverage was earned.

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    2(a)(4) Social Insurance Number Used While Working - Enter the foreign social insurance number under which a particular period of coverage was established.

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    2(a)(5) Name of Agency to Which Contributions Paid - Enter the name of the foreign agency to which the contributions were paid.

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    Sub-item 2(b) asks for information about any periods of coverage credited to the worker that are not based on employment or self-employment. These periods of coverage may include periods based on voluntary contributions or deemed equivalent periods for military service, illness, child rearing, school attendance, etc. Enter “unknown” if any of the information is unknown.

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    2(b)(1) Dates Covered - Enter the dates for which these periods of coverage were credited. Where the worker had two or more non-continuous periods or periods were credited for different reasons (e.g., a period based on voluntary contributions followed immediately by a period based on school attendance) list each period separately.

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    2(b)(2) Type of Coverage - Enter the type of coverage; e.g., military service, voluntary contributions, etc.

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    2(b)(3) Social Insurance Number Used for This Coverage if Different From Item 2(a)(4) - Enter the foreign social insurance number under which the coverage was established if different from the number in item 2(a)(4).

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    2(b)(4) - Name of Agency to Which Contributions Paid (if any) - Enter the name and address of the agency to which any contributions were paid.

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    Sub-item 2(c) asks for the worker's last place of residence in the foreign country. This information may be needed to locate the worker's foreign coverage record. If the name of the city is not known, attempt to obtain the name of the State, province, territory, etc. Enter “unknown” if this information is not known.

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  Item 3 - Enter the name of the foreign country from which benefits are being claimed.

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  Item 4 - This item asks for information about the type of benefit(s) being claimed from the foreign country and/or the United States. Both foreign and U.S. benefits may be indicated and more than one type of benefit may be claimed on one Form SSA-2490-BK. If an applicant selects a benefit that seems inappropriate (e.g., a 70-year-old worker selects a disability benefit), have the applicant explain in the Remarks section (item 19) or on Form SSA-795 the reason for doing so.

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    Benefit Claimed From Foreign Country – Check the appropriate box for the type of benefit(s) being claimed from the foreign country. If the applicant checks “Other” enter the name of the benefit in the space provided. The types of benefits paid by each country are described in the subchapter pertaining to that Agreement.

    Check the “None” block when an applicant wishes to claim benefits from the United States but not from the foreign country.

    NOTE: It is important that the “None” block be checked in this situation so that it is clear the applicant has chosen to restrict the scope of the application to United States Benefits only.

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    Benefit Claimed From the United States – This section asks whether the applicant is already receiving benefits from the United States. The sub-items are self-explanatory.

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  Item 5 - This item asks for additional information about the worker (living or deceased) on whose record the claim is based.

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    Sub-items 5(a) - 5(d) Self-explanatory

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    Sub-item 5(e) - Enter the country of the worker's citizenship as of the date of the application in life claims or as of the date of death in survivor claims. If the worker holds/held dual citizenship, enter the name of each country. If the worker is/was not a citizen of any country (i.e., stateless), enter “None.”

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  Item 6 - Check the “Yes” block if the applicant wishes Form SSA-2490-BK to serve as a protective writing for the spouse or children of the worker who may be eligible for U.S. benefits but who may not be named specifically on the application. Although items 16 and 17 of Part II asks for the names of the worker's dependents or survivors, an applicant claiming only U.S. benefits under an Agreement is not required to complete Part II.

  If the applicant checks “Yes” in item 6, Form SSA-2490-BK becomes a protective writing for all classes of benefits for an eligible spouse or children. Names and other required information will be obtained on the regular retirement, survivors, or disability application(s).

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  Item 7 - Indicate whether the worker or any other person claiming benefits on the worker's record is or ever was a refugee or stateless person. This information is needed because some Agreements exempt certain refugees and stateless persons from the alien nonpayment provisions of Title II, or from similar nonpayment provisions of the foreign country's laws (see GN 01702.225 concerning the need to develop refugee or stateless status).

Complete Part II whenever the applicant indicates in item 4 that foreign benefits are being claimed under any Agreement other than the Agreements with Australia, Canada, Japan, South Korea or Spain. If the applicant is claiming Totalization benefits from the United States and foreign benefits only from Australia, Canada, Japan, South Korea or Spain, all questions in Part II should be left blank. Do not use the SSA-2490-BK if the applicant is filing only for Australian, Canadian, Japanese, Korean or Spanish benefits and not U.S. benefits. There are special application forms that must be used to apply for benefits from Australia (see GN 01743.215), Canada (see GN 01715.220), Japan (see GN 01745.215 through GN 01745.220), South Korea (see GN 01741.215) and Spain (see GN 01721.220).

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  Items 8 - 9 - Self-explanatory

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  Item 10 - Some countries have a general social security system that covers most workers plus one or more special systems that cover workers in certain occupations or industries. Item 10 asks for information about the worker's participation in any special systems. If sub-item 10(a) is answered “yes” complete the remaining sub-items.

  Refer to the individual Agreement subchapters to determine if the foreign country covers specific occupations and to determine what evidence may be needed to support the claim.

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  Item 11 - Complete item 11 only if the applicant is not the worker. The sub-items are self-explanatory.

  NOTE: Items 12-15 ask for additional information about the worker that may be needed by the foreign country.

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  Item 12 - Self-explanatory

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  Item 13 - If the worker is living, enter “N/A.” If the worker is deceased but the information is unknown, enter “Unknown.”

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  Item 14 - Show any foreign military service, even if it was for a country other than the country from which benefits are being claimed. The sub-items are self-explanatory. Enter “Unknown” if the requested information is unknown.

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  Item 15 - Evidence of U.S. lag earnings may be needed to provide a complete record of U.S. coverage to the foreign country. The sub-items are self-explanatory.

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  Item 16 - If both questions in sub-item 16(a) are answered “No,” go to question 17. Otherwise, complete the remaining sub-items.

  Refer to the individual Agreement subchapters to determine the ages at which children are eligible for benefits from a foreign country. Also, if a child is disabled or a student, refer to the individual Agreement subchapter to determine what evidence may be needed to support the claim.

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  Item 17 - This item asks for information to help identify a spouse or former spouse(s) who may be eligible for benefits on the worker's record. If there are more than two former spouses, obtain information about the additional former spouses on a separate statement. Enter “Unknown” if any of the information is not known.

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  Item 18 - Use the following instructions for completing each sub-item.

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    Sub-item 18(a) - Self-explanatory

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    Sub-item 18(b) - Enter the name(s) of the individual(s) who previously applied for benefits.

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    Sub-item 18(c) - Enter the type of benefit. See the individual Agreement subchapters for the types of benefits paid by the foreign countries.

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    Sub-item 18(d) - Enter the U.S. claim number if U.S. benefits were claimed and the foreign social insurance number if foreign benefits were claimed.

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    Sub-item 18(e) - If benefits were awarded, enter the amount of the benefit in U.S. dollars or the currency of the foreign country. If a foreign benefit was awarded and is paid on other than a monthly basis, also indicate the frequency of the payment.

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    Sub-item 18(f) - Enter the name of the agency that approved or denied the prior claim (e.g., for U.S. benefits enter “SSA”). Enter “Unknown” if the name is not known.

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  Item 19 - Use this space for any additional statements.