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.