Check the appropriate blocks for the Portuguese agency and the U.S. office.

Always complete items A - C.

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  Item A - Enter the first name(s), middle and last name of the worker. Also, show the worker's name at birth if it is different.

For Portuguese nationals, show the complete name in the order in which it is shown on the worker's Portuguese identity card or passport.

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  Item B - Enter the worker's U.S. Social Security number.

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  Item C - Enter the worker's nine digit Portuguese social insurance number as shown on the application form or on the Portuguese liaison form. If the number has not been furnished, enter “unknown”.

Complete items D and E if you are transmitting a claim or protective filing date to the Portuguese agency.

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  Item D - Enter the type of Portuguese benefits that are being claimed. If the claim is for disability benefits, and there is evidence that the disability is the result of a work-related injury or disease, check the “Work-Related” block.

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  Item E - Enter the filing date to be certified to the Portuguese agency.

Always complete Item F unless you are responding to an assistance request from a Portuguese agency.

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  Item F - Enter the claimant's name only if the claimant is not the worker. Always enter the claimant's address.

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  Name - Always enter the names of all claimants and in survivor cases, the name of the deceased worker.

Enter the first name, middle and last names and if applicable, the maiden name. For Portuguese citizens, show the complete name in the order shown on the Portuguese identity card or passport.

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  Date of Birth - Enter the date of birth for all claimants and for the deceased worker.

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  Verified - (Completed only by OIO) Check this block if:

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    the date of birth has been used to award U.S. benefits, or the date of birth is shown on the MBR as proven.

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  Monthly Benefit and Effective Date - (Completed only by OIO) Complete these blocks when benefits have been awarded if:

A claim for Portuguese benefits is or has been transmitted, or a Portuguese agency has requested the information.

For retirement or disability claims, enter the MBC for the worker and spouse effective with the first month of entitlement or August 1989, whichever is later.

For survivor claims, enter the MBC for the deceased worker effective with the month prior to the month of death. Enter the MBC for the widow and surviving children effective with the first month of entitlement for survivor benefits or August 1, 1989, whichever is later.

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  Date of death, marriage and divorce - Complete these items only if transmitting a claim for Portuguese benefits, or responding to a Portuguese agency request.

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  “Verified” - (Completed only by OIO) Check this block if the data has been used to award U.S. benefits, or the data is shown on the MBR as proven.

Check at least one block to indicate the type of material being sent to the Portuguese agency.

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  Check A if attaching a U.S. coverage record.

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  Check B if attaching medical evidence submitted by the claimant or from SSA files.

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  Check C if responding to a request from the Portuguese liaison agencies and enter the date of the request.

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  Check D if no material is attached.

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  Check E if attaching material not covered by any block shown above and briefly explain the attachment.

Check at least one block to indicate the type of material being requested from the Portuguese agency.

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  Check A if requesting a Portuguese coverage record.

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  Check B if requesting a copy of medical evidence from the Portuguese agency's files.

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  Check C if following up on an earlier request to the Portuguese agency and show the date of the request.

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  Check D if you are not requesting any information.

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  Check E if you are requesting information not covered by a block shown above. Briefly explain your request.

Keep remarks to a minimum and make them clear and concise. Never use technical jargon or abbreviations.

Sign and date the form before it is released.