TN 2 (09-85)

GN 01704.420 Totalization Applications and Foreign Forms

A. U.S./Italian Agreement

Two application forms have been devised for claiming totalization benefits under the U.S./Italian agreement. (See GN 01705.215 and GN 01705.220.)

  1. The Form SSA-3954-BK-IT (Application for Benefits Under the Italy/ United States International Social Security Agreement)—This application is filed in the United States and claims-taking FSPs.

  2. The IT/USA 1 (Italy/U.S.A. Agreement on Social Security—Application for Benefits)—This application is filed with INPS.

    In addition to the application IT/USA 1, INPS uses the following forms:

  3. IT/USA 2—Transmittal/request form used by INPS to transmit information and material to OIO and to request information and material from OIO.

  4. IT/USA 3—A liaison form used by INPS to convey information to OIO and request earnings information from INTPSC. This form is usually included with the IT USA 1.

  5. IT/USA 3 bis - (“bis” means attachment)—An Italian earnings certificate.

  6. IT/USA SS-3—Medical Report

  7. IT/USA 4—An Italian coverage certificate which relays information about the worker and his or her employer.

  8. IT/USA 5—INPS' response to OIO's request for Italian earnings.

  9. IT/USA 6—Request for claimant's choice of benefit.

  10. IT/USA 7—Statement of interest to file for U.S. benefits in the future.

  11. IT/USA 8—Notice to claimant of INPS determination on a totalization claim.

  12. IT/USA 9—Transmittal/request form.

  13. IT/USA 10—Italian agency development request form.

  14. IT/USA 11—Request for Medical Examination.

B. U.S./German Agreement

Three application forms have been devised for claiming totalization benefits under the U.S./German agreement. (See GN 01707.215.

  1. The SSA-3957-F6 (Application for Benefits Under the United States-Federal Republic of Germany International Social Security Agreement)

  2. The D/USA 1 (Application for Insurance Benefits from the German Pension Insurance)—This is an application for use by U.S. residents who apply for German retirement, disability and/or the child's supplement. This form is stocked in DOs and OIO; FSPs in Germany and elsewhere do not stock or use this application. Persons filing for German benefits outside the United States must complete regular German applications.

  3. The D/USA 2 (Application for Survivors Benefits from the German Pension Insurance)—This is an application for U.S. residents who apply for survivors benefits from Germany. This form is stocked in DOs and OIO; FSPs in Germany and elsewhere do not stock or use this application. Persons filing for German benefits outside the United States must complete regular German applications.

    In addition to the applications, several forms have been devised to enable the German agencies to communicate with OIO. They are:

  4. D/USA 3—Transmittal/Request Form.

  5. D/USA 4—Liaison Certification Form. May be used to certify no German earnings in Part II, 2d), in lieu of D/USA 5.

  6. D/USA 5—German Earnings Record.

  7. D/USA 6—Medical Evaluation (No longer in use.)

  8. D/USA 6A—Disability Liaison Form—Request for medical information or examination.

  9. D/USA 7—Declaration of Consent.

  10. D/USA 8—Information needed for issuance of German work record. Completed if claimant has restricted application to U.S. benefits and has not previously filed a claim with Germany.

C. U.S./Swiss Agreement

Four applications have been devised in connection with claims under the U.S./ Swiss totalization agreement. (See GN 01709.215-GN 01709.220.)

  1. SSA-4231-F6 (Application for Benefits Under the Switzerland/U.S. International Social Security Agreement)—Not needed by Swiss agency.

  2. CH/USA 2.1 (Application for an Old-Age Pension for Citizens of the United States of America Residing Outside Switzerland)—Persons who are U.S. nationals, refugees, stateless persons or third country nationals who derive rights and reside outside Switzerland must complete this form when they apply for a Swiss old-age pension. This form is stocked only by OIO.

  3. CH/USA 2.2 (Application for a Survivors Pension for Citizens of the United States of America Residing Outside Switzerland)—Persons who are U.S. nationals, refugees, stateless persons or third country nationals who derive rights and reside outside Switzerland must complete this application when applying for survivor benefits from Switzerland. This form is stocked only in OIO.

  4. CH/USA 2.3 (Application for Disability Insurance for Citizens of the United States of America Residing Outside Switzerland)—Persons who are U.S. nationals, refugees, stateless persons or third country nationals who derive rights and reside outside Switzerland must complete this application when they apply for a Swiss disability benefit. This form is stocked only in OIO.

    NOTE: Swiss nationals complete applications for Swiss benefits in Swiss diplomatic offices or in any office of the CSC.

    In addition to the applications, the following Swiss forms have been devised for use in processing Swiss claims:

  5. CH/USA 3—Swiss Liaison Form;

  6. CH/USA 5—Swiss Earnings Certificate;

  7. CH/USA 6A—Disability Liaison Form;

  8. CH/USA 6—Medical Evaluation Form;

  9. CH/USA 7—Consent Form

D. U.S./Norwegian Agreement

Four applications have been devised in connection with claims filed under the U.S./Norwegian agreement. (See GN 01711.215.)

  1. SSA-796 (Application for Benefits Under the U.S.-Norway Agreement)—This form is not needed by Norway and should not be forwarded to the FFU.

  2. N/USA 1.1 (Application for an Old-Age Pension for Norway)—Persons who reside in the United States must complete this application to claim old-age pensions from Norway. This form is stocked only by OIO.

  3. N/USA 1.2 (Application for a Disability Pension from Norway)—Persons who reside in the United States must complete this application to claim disability pensions from Norway. This form is stocked only by OIO.

  4. N/USA 1.3 (Application for a Survivor Pension from Norway)—Persons who reside in the United States must complete this application to claim survivor pensions from Norway. This form is stocked only by OIO.

    In addition to the applications, the following Norwegian forms have been devised to process claims under the U.S.-Norwegian agreement.

  5. N/USA 3 (Norwegian Transmittal Request/Certification Form)

  6. NS/USA 7 (Consent Form)

E. U.S.-Belgian Agreement

Only one application has been devised in connection with claims filed under the U.S.-Belgian agreement. (See GN 01713.215.)

  1. SSA-799 (Application for Benefits Under the U.S./Belgian Agreement)—This form is not needed by the Belgian agencies.

    In addition to the SSA-799, the following Belgian forms have been devised to process claims under the U.S.-Belgian agreement.

  2. BE/USA 3 (Transmittal/Request/Certification Form)

  3. BE/USA 5 (Belgian Coverage Certification Form (Manual Certifications Only))

  4. BE/USA 7 (Consent Form)

F. U.S./Canadian Agreement/Quebec Understanding

Four applications have been devised in connection with claims filed under the U.S./Canadian Agreement/Quebec Understanding. (See GN 01715.220, GN 01715.225, GN 01715.230 and GN 01715.335.)

  1. SSA-1294-F5-CN (USA/CAN 1, Application for Benefits Under the Canada-U.S. International Social Security Agreement)—This application must be completed when a claim is filed for benefits from the U.S. under the agreement /understanding unless the claim is filed in the province of Quebec. This form is stocked in INTPSC, U.S. DOs, claims-taking FSPs and Canadian CPP offices.

  2. SSA-1295-F4-QU (USA/QUE 1, Understanding Between the United States of America and Quebec on Social Security. Application for United States Benefits)—This application must be completed when a claim is filed for benefits from the U.S. under the agreement/understanding in the province of Quebec. This form is stocked in Quebec only.

  3. CAN/USA 1 (Application for Canadian Benefits Under the Agreement on Social Security Between Canada and the United States)—Persons who file with SSA for Old-Age Security (OAS) or CPP benefits from Canada must complete this form. This form is stocked in DOs, claims-taking FSPs and OIO.

  4. QUE/USA 1 (Understanding Between Quebec and the United States of America on Social Security. Application for Benefits Under the Quebec Pension System)—Persons who file with SSA for QPP benefits from Quebec must complete this form. This form is stocked in DOs, claims-taking FSPs and OIO.

    In addition to the applications, the following Canadian forms have been devised to process claims under the U.S.-Canadian Agreement/Quebec Understanding:

  5. CAN/USA 2 (Transmittal and Liaison Form)

  6. QUE/USA 2 (Transmittal and Liaison Form)


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0201704420
GN 01704.420 - Totalization Applications and Foreign Forms - 08/08/2014
Batch run: 08/08/2014
Rev:08/08/2014