When a person not eligible for Czech benefits contacts the Czech Republic agency,
CSSZ to file a claim for U.S. benefits, CSSZ sends the following information to the
FSP in Warsaw, Poland:
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SSA-2490-BK (Application for Benefits under the U.S. International Social Security
Agreement) and Supplemental Questionnaire (This form can be located on the Division
of International Operations website).
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•
A liaison form, SSA-e2960-U3-CZ(Transmittal/Request/Certification Form-CZ/USA3), certifying
the filing date for the claim.
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Czech certified coverage record (CZ/USA205)
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•
Available medical evidence if the claim is for disability benefits.