Effective Dates: 04/26/2017 - Present Previous | Next

Basic (04-09)

GN 01750.205 Preparing Claims Packages in DIO for Claims Filed Outside of the Czech Republic

A. Procedure – Initial claims packages

Prepare initial claims packages to request Czech Republic certified coverage records and to inform CSSZ about claims for Czech benefits.

B. Procedure – U.S. claims

Prepare form SSA-e2960-U3-CZ (Transmittal/Request/Certification -USA/CZ3) and forward it to CSSZ if the Czech record is not in the claims file.

C. Procedure - U.S. claims/Czech totalization benefits

Prepare a claims package that includes:

  • •

    Form SSA-e2960-U3-CZ USA/CZ3 to request a Czech Republic certified coverage record if needed and to certify the filing date for Czech benefits, establish factors of entitlement, and U.S. benefit information.

  • •

    A U.S. totalization earnings record.

  • •

    Medical evidence from SSA’s files, if the Czech claim is for disability benefits.

  • •

    CZ/USA 202 and any necessary proofs and any evidence

  • •

    Letter to claimant advising them that their claim was forwarded to the Czech Republic Agency if claim is for Czech benefits only.

D. Reference

GN 01750.205 – GN 01750.220, Application and Evidence for Czech Agreement

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0201750205
GN 01750.205 - Preparing Claims Packages in DIO for Claims Filed Outside of the Czech Republic - 04/26/2017
Batch run: 04/26/2017
Rev:04/26/2017