Enter the date you are completing the form in the “DATE OF ORIGINAL” block. Enter the DATE(S) OF FOLLOW-UP(S) as appropriate. When sending a first or second follow-up, document the blue file copy with the follow-up date. Use a new form for third follow-ups and retain all blue copies in file.

• •

  Refer to GN 01730.025 to determine the proper office

• •

  use the pre-addressed labels or block print the name and address of the Austrian office as appropriate in the “TO” block

Complete the items in Part I as follows:

• •

  Item A - always enter the first, middle and last names of the worker

• •

  Item B - always enter the worker's U.S. SSN

• •

  Item C - always enter the worker's Austrian Insurance number if it is shown on the application or on the Austrian Liaison form.

  Note: The Austrian number consists of ten digits. The first are assigned in sequence but the last 6 represent the worker's date of birth in day, month, year order.

• •

  Item D - enter the filing date being certified to the Austrian agency on all initial claims packages and in response to an Austrian agency's request for the filing date.

• •

  Item E - on initial claims packages indicate the type of claim for Austrian benefits.

• •

  Item F - complete the name and address block in all initial claims packages and in response to an Austrian agency's request for address information.

• •

  Item G - on initial claims packages enter the claimant's telephone number, including area code if it is shown on the application.

• •

  Item H - on initial claims packages, enter the claimant's relationship to the worker.

Complete the Certification of Data part of the form when transmitting a claim for Austrian benefits or when replying to an Austrian agency's request for specific information.

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  Names (Items A.1. and B.1.)-Enter the first, middle and last names of all claimants and if applicable, the maiden name (item B.2.)

• •

  Dates - Enter the applicable dates in month, day, year format for all claimants named.

• •

  Verified - If a date has been entered, check the “verified” block if the date has been used to award U.S. benefits or the date is shown on the MBR as proven. Otherwise, leave the block blank.

  NOTE: Verified blocks should not be checked by FSP personnel.

• •

  Place of Birth - For foreign born workers enter the name of the city, town etc. followed by the name of the country. For U.S. born workers, enter the city/town, the state and “U.S.A.”.

• •

  Sex - Enter M or F as appropriate for the worker.

• •

  Periods of Disability (Item A.5.)-Leave this block blank.

• •

  Worker's Benefit Data (Item A.7)-In retirement (old age) and disability cases, enter the first month and year for which the worker was paid full benefits or the effective date of the agreement whichever is later. If benefits have not been awarded, or have been completely withheld or suspended since the month of entitlement, enter “none”.

  Following the month and year, enter the worker'sfull Monthly Benefit Credited (MBC) for that month, as determined following GN 01730.330.D.

  If the worker is receiving benefits only as a spouse or widow on another record, write in “spouse's benefits only” or “widow's benefits only” after the MBC.

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  Survivor's Benefit Data (Item B.7.)-In survivor cases, enter the first month and year for which a widow, widower or surviving former spouse (i.e. divorced spouse) was paid full benefits (retirement, disability or survivors on any SSN) or the effective date of the agreement whichever is later. If benefits have not been awarded, or have been completely withheld or suspended since the month of entitlement, enter “none” .

  Following the month and year, enter the survivor's full MBC for that month, as determined following GN 01730.330.D.

  Disregard the RET and DIB boxes in item B.7.

• •

  Citizenship and Country of Residence (Items A.8.,A.9.,B.8., and B.9.)-Enter the alleged citizenship and country of residence on initial claims packages and attach any evidence of citizenship to the form. (See GN 01730.320 for instructions.)

Complete this part of the form when:

• •

  transmitting a child(ren) claim for Austrian benefits, or

• •

  replying to an Austrian agency's request for specific information about the child(ren).

  NOTE: Follow the rules in 4 above for entering children's names and dates of birth and checking the verified block. Enter the names and dates of birth of additional children in Part VI, Remarks.

Check at least one block to indicate the type of material being sent to the Austrian agency. Check item:

•A.

if attaching a U.S. earnings record.

•B.

if responding to a request from an Austrian agency and enter the date of the request.

•C.

if attaching medical evidence submitted by the claimant or from SSA files and enter the claimant's name.

•D.

if attaching material not covered by any block shown above and briefly explain the attachment.

Check at least one block to indicate the type of material being requested from the Austrian agency. Check item:

•A.

in every case in which you are requesting anything from an Austrian agency.

•B.

if you are requesting an Austrian coverage record.

•C.

if you are following up on an earlier request to an Austrian agency and show the date of the request.

•D.

if you are requesting information not covered by a block shown above. Briefly explain your request in remarks.

Keep remarks to a minimum and make them clear and concise. Do not use technical jargon or abbreviations. Be sure to sign, date and apply the OIO stamp. Include specific remarks in the following situations:

• •

  If the field office has entered the name of any Austrian agencies to which the NH contributed in the remarks section of Form SSA-2490-F4, inform HOS of this by entering “Worker alleges contributions to: (enter agencies' names as provided by claimant).”

  Note: Development of this information whether through the field office or directly with the claimant is not necessary.