Complete the Certification of Data part of the form when transmitting a claim for
German benefits. When replying to a German agency's request for specific information,
complete only the specific items needed.
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Item a) Date of Birth – Name(s) - Enter the first and last names of all claimants
and if applicable, the maiden name. Enter the date of birth in month, day, and year
format for all claimants named. Place of Birth column - For foreign-born workers,
enter the name of the city, town, etc. followed by the name of the country.
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For U.S. born worker, enter the city or town, the state, and “U.S.A.”
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Item b) Date of Death - Enter the date of death if applicable.
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Item c) Date of Marriage - Enter the date of marriage if applicable.
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Item d) Date of Divorce - Enter the date of divorce if applicable.
NOTE: Verified Column- If you entered a date, check the “verified” block if we used the
date to award U.S. benefits or the Master Beneficiary Record (MBR) or Numident show
the date as proven. Otherwise, leave the “verified” block blank.
FSP personnel should not check “Verified” blocks.
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Item e) Sex of Worker - Select M (male) or F (female) as appropriate for the worker.
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Item f) Periods of Disability - Do not complete this block.
If a German agency requests information about a period of disability, refer the case
to the DIO Division Analyst with your supervisor’s guidance.
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Item g) Citizenship - Enter the alleged citizenship on initial claims packages and
attach any evidence of citizenship to the form.
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Item h) Country of Residence - Enter the country of residence on initial claims packages.
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Item i) Benefit Data - If the worker, widow(er), or former spouse is entitled to a
retirement insurance benefit (RIB) or disability insurance benefit (DIB) on this SSN,
enter the effective date and the monthly benefit credit (MBC), as determined in GN 01708.320. If you identify a person as a widow, widower, or former spouse, enter the effective
date and MBC of his or her own RIB or DIB, as determined in GN 01708.320 and check the Retirement or Disability block as appropriate.
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Item j) If the Worker, widow, widower, or former spouse is entitled to Medicare Part
A or Part B, check the appropriate boxes and enter the effective date.
If a widow, widower, or former spouse is not entitled to RIB or DIB on his or her
own SSN, inform the German agency that the claimant is not entitled to retirement
or disability benefits.
If we suspended or withheld benefits since the first month of entitlement, consult
a Benefit Technical Examiner (BTE) or Claims Technical Examiner (CTE) to determine
the reason and explain it to the German agency in Part V REMARKS section.