The Canadian application forms (CAN/USA 1 and QUE/USA 1) are used to certify the date claim filed and to certify information as verified when that information has been used to adjudicate a claim for benefits from the United States. Each form contains a section below the signature block designed for this purpose.

This section is used to verify, for Ottawa, that certain eligibility factors identified in this section have been established. Except for the date of application which must be entered in all cases, verification is provided only when SSA has established the date in connection with a concurrent RSDI claim or the date had been established in connection with a prior claim and the date is available from the MBR.

When any of the factors have been verified, the individual doing the verification must enter his/her initials in the “Verified by” block for the particular factor. When any factor has been shown as verified in this section, do not forward any evidence for that factor to Ottawa along with the claims package. The individual completing this section must date and sign the section in the space provided including the title (e.g., BET).

Note: Other than the date of application, make no entry unless the factor has been established by SSA and is being verified.

This section is used to verify, for Quebec, that certain eligibility factors identified in this section have been verified.

Always enter the date of filing. Enter the date of birth, date of death or date of marriage when applicable. If the date has been established in connection with a concurrent RSDI claim or if the date had been established in connection with a prior claim and the date is available from the MBR, place an “X” in the verified block for the particular date involved. When any date has been shown as verified in this section, do not forward any evidence for that factor to Quebec along with the claims package.

NOTE: Other than the date of filing, make no entry unless the factor has been established by SSA and is being verified.

Enter the name and address of the office in the space designated Full name of Department (e.g., DIO, Baltimore, Maryland). The individual completing this section must date and sign this section in the space provided and print his/her name along with his/her title (e.g., BET). Stamp the section in the space provided with the stamp.

The certification sections on the CAN/USA 1 and QUE/USA 1 are for use by DIO and designated border DOs only. However, occasionally, these sections may be completed and signed by unauthorized persons, usually nondesignated DO personnel. When this happens, carefully check the entries. Then make the following entries using a different color ink. If correct, add your initials to the “Verified by” block of the CAN/USA 1. DO NOT place an additional “X” in the “Verified” block of the QUE/USA 1. If an entry is incorrect, line it out, enter the correct date and add your initials to the “Verified by” block on the CAN/USA 1. Place an additional “X” in the “Verified” block of the QUE/USA 1. Enter the current date, your signature, title and DIO in the appropriate spaces. Affix the DIO stamp.