Effective Dates: 05/05/2017 - Present Previous | Next

Basic (07-09)

GN 01752.235 Facts about the ZUS or KRUS Liaison Form PL/USA 3

A. Procedure – When Form PL/USA 3 Will Be Used

ZUS or KRUS will use the form PL/USA3 to:

  • •

    Transmit material to DIO or to the FSP in Warsaw.

  • •

    Send information to DIO or to the FSP in Warsaw.

  • •

    Request information from DIO.

B. Form PL/USA 3 – Transmittal/Request/Certification

Description of the Form PL/USA3

1. Part 1

Part 1 contains information about the claim and the claimant.

2. Part 2

Part 2 contains certification of data. If verified, the appropriate block will be checked.

3. Part 3

Part 3 contains information provided by the ZUS or KRUS agency, including medical evidence in disability claims.

4. Part 4

Part 4 contains a list of the type of information that the ZUS or KRUS agency might request from DIO/FSP in Warsaw Poland along with the remark that the information is needed to process a claim under the agreement or that a consent statement is attached.

5. Part 5

Part 5 contains any necessary remarks.

C. Exhibit of Form PL/USA3

The form PL/USA 3 may be printed from the SSA Totalization Forms section of the Totalization Resource Kit on the Division of International Operations (DIO) webpage.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0201752235
GN 01752.235 - Facts about the ZUS or KRUS Liaison Form PL/USA 3 - 05/05/2017
Batch run: 05/05/2017
Rev:05/05/2017