| TO: |
Note that this block is pre-printed with the address of the CPSI. When mailing to
the SII, place the SII label over the preprinted CPSI address.
|
| FROM: |
Check the appropriate block. |
| I. Information About the Claim |
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 Finnish Population Register Number if it is shown
on the application or on the Finnish liaison form.
-
•
Item D - on initial claims packages indicate the type of claim for Finnish and/or
U.S. benefits.
-
•
Item E - enter the filing date being certified to the Finnish agency on all initial
claims packages and in response to a Finnish agency's request for the filing date.
-
•
Item F - complete the name and address block in all initial claims packages and in
response to a Finnish agency's request for address information.
|
| II. Certification of Data - Item A |
Complete the Certification of Data part of the form when transmitting a claim for
Finnish benefits or when replying to a Finnish agency's request for specific information.
|
| |
-
•
Name - Always enter the names of all claimants and in survivor cases, the name of
the deceased worker. Enter the first name, middle and last names and, if applicable,
the maiden name.
-
•
Date of Birth - Enter the date of birth for all claimants and for the deceased worker.
-
•
Verified - (Completed only by OIO) Check this block if the date of birth has been
used to award U.S. benefits; OR
the date of birth is shown on the MBR as proven.
-
•
Entitled Since and Monthly Amount (Completed only by OIO) - Complete these blocks
when benefits have been awarded if a claim for Finnish benefits is or has been transmitted;
OR a Finnish agency has requested the information and a signed authorization is in file.
For retirement or disability claims, enter the MBA for the worker and spouse effective
with the first month of entitlement or November 1992, whichever is later.
For survivor claims, enter the MBA for the deceased worker effective with the month
prior to the month of death. Enter the MBA for the widow and surviving children effective
with the first month of entitlement for survivor benefits or November 1, 1992, whichever
is later.
NOTE: Benefit amounts shown should be the amount before reduction for nonresident alien
tax, SMI premiums, etc.
|
|
II. Certification of Data - Item B
|
-
•
Date of death, marriage and divorce Complete these items only if transmitting a claim
for Finnish benefits, OR responding to a Finnish agency request.
|
| |
-
•
“Verified” (Completed only by OIO) - Check this block if the data has been used to award U.S.
benefits, OR the data is shown on the MBR as proven.
-
•
ALWAYS show the date of last employment in Finland because field offices should obtain this
information. (See GN 01731.215C regarding remarks about work information). Develop directly with claimant if this
information is missing.
|
| III. Transmitted |
Check at least one block to indicate the type of material being sent to the Finnish
agency. Check item:
|
| |
-
A. if attaching a U.S. coverage record.
B. if attaching medical evidence submitted by the claimant or from SSA files.
C. if responding to a request from the Finnish liaison agencies and enter the date
of the original request.
D. if no material is attached.
E. if attaching material not covered by any block shown above and briefly explain
the attachment.
|
| IV. Requested |
Check at least one block to indicate the type of material being requested from the
Finnish agency. Check item:
|
| |
-
A. if requesting a Finnish coverage record.
B. if requesting a copy of medical evidence from the Finnish agency's files.
C. if following up on an earlier request to the Finnish agency and show the date of
the original request.
D. if you are not requesting any information.
E. if you are requesting information not covered by a block shown above. Briefly explain
your request.
|
| V. 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.
|