Basic (08-94)
The Dutch agencies use liaison form NL/VS3 to:
transmit material to DIO or the FSPs in London and Dublin
send information to DIO or the FSPand
request information from DIO
NL/VS 3
NETHERLANDS/USA AGREEMENT ON SOCIAL SECURITY
To:
Social Security Administration Division of International Operations P.O. Box 17769 Baltimore, Maryland 21235–7769 USA
From:
U.S. Embassy, FBU, 42 Elgin Rd, Ballsbridge, 4 Dublin, IRELAND
INFORMATION ABOUT THE CLAIM
Name of worker
Dutch Social Insurance Number
U.S. Social Security Number
Type of Claim
U.S.
Dutch
old age
survivor
disability
( )
Date of Claim
day
month
year
Name and Address of Claimant
VERIFICATION OF INFORMATION
The Worker
date of birth
date of marriage
date of divorce
Name
MATERIAL ATTACHED
( ) No Material
( ) Dutch Insurance Record (NL/VS 205)
( ) Medical Evidence
( ) Information Requested on
day/month/year
( ) Other (see remarks)
INFORMATION REQUESTED FROM U.S.A. This information is needed to process a claim under the agreement. ( )Yes ( )No
( ) No Information Needed
( ) Entitlement moneth and benefit amount for:
( ) US Insurance Record
( ) Status of Request Dated day/month/year
REMARKS
STAMP
Part 1 (INFORMATION ABOUT THE CLAIMS) contains general information about the claim including, if known, the U.S. SSN
Part 2 (VERIFICATION OF INFORMATION) contains spaces for the Dutch agencies to indicate the claimants' names, dates of birth and other event dates and to indicate whether these dates have been verified by acceptable evidence.
Part 3 (MATERIAL ATTACHED) contains information from the Dutch agency that indicates whether evidence is attached.
Part 4 (INFORMATION REQUESTED FROM USA) contains a list of the types of information that a Dutch agency might request from DIO. A check in block b., “an agreement claim has been made” constitutes authority to disclose information to the Dutch in the absence of a signed U.S. application form SSA-2490, Dutch application form NL/VS 202 or 203 or other signed statement.
In the REMARKS portion the Dutch agencies often ask for a form “VS/ NL 205” . Such a form does not exist, however, in these instances the Dutch agencies are really requesting a U.S. earnings record.
A Dutch agency's request for a “copy of the decision” means that they want to know the claimant's month of entitlement to U.S. benefits and the monthly benefit amount. See GN 01726.220.D.4