This section is completed only by staff in the Office of International Operations (OIO) or one of the designated
border offices (at the Claims Representative level or higher) identified in GN 01715.320. It informs the Quebec agency which, if any, of the eligibility factors shown have
been verified for SSA purposes.
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Always enter the date claim filed in the first block. This date will be the date of
filing in the FO or an earlier protective filing date, if applicable.
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Make entries in the remaining blocks only if the relevant date has been established
for SSA purposes either in connection with a
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concurrent retirement, survivors or disability claim, or
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prior claim and the date is available from the master beneficiary record (MBR).
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For each date established by SSA, enter the date in the appropriate space and check
the “Verified” box. (The date that has been proven for SSA purposes is entered even if different
than the alleged date.)
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If SSA has not established a particular date, make no entry.
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When surviving spouse's benefits are claimed, enter the surviving spouse's name and
date of birth (if established for SSA purposes) in the appropriate space and check
the “Verified” box.
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Enter any children's names and dates of birth (if established for SSA purposes) in
the appropriate spaces and check the “Verified” box.
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Enter the name and address of the office in the space designated “Name of the Institution” (e.g., SSA field office, Burlington, Vermont).
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Sign and date in the space provided and also print the name and title of the individual
completing this section.
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Stamp the section in the space provided with the date stamp used to date stamp applications
for U.S. benefits.