TN 2 (09-85)
GN 01704.715 Liaison Certification Forms (SSA-1279, SSA-1280, and SSA-1281)
COMPLETE THESE FORMS IN LEGIBLE BLOCK PRINTING.
These forms are used to transmit information about claimants from our files to foreign agencies. Foreign agencies will accept data marked “verified” on these forms as valid and factual. Therefore, when vital statistic data are provided, check either “verified” or “alleged” to indicate whether the data are verified by SSA records or merely alleged by the claimant.
There is no need to complete these forms if the foreign agency does not need the information. Therefore, complete liaison forms only if you are forwarding the application for benefits to that agency and certifiable data are available from the MBR or the RSDI claims folder; or the foreign agency has requested the information. Do not complete the form if the foreign agency has requested an earnings record for a claim filed with the agency—assume, unless specifically requested, that the foreign agency has all the vital statistics needed.
The liaison certification Form SSA-1279 concerns general and identifying information about the worker.
The liaison Form SSA-1280 concerns general and identifying information about the spouse, former spouse or widow(er) of the worker.
The liaison Form SSA-1281 concerns all other claimants on the worker's record.
B. Italian liaison forms (SSA-1279-U3-IT, SSA-1280-U3-IT and SSA-1281-U3-IT) (See GN 01706.320)
1. Part I.—Data about the primary claimant
Liaison Form SSA-1279-U3-IT—part I, a., b. and c. requests information about the “primary claimant.” The “primary claimant” is the individual who filed the survivors claim or the individual who filed a life claim on behalf of the worker. If the worker filed the claim, the entries in part II., 1., a., b. and c. will be the same as those in part I.
Complete part I and part II.1, Data About the Worker, on Form SSA-1279-U3-IT in addition to Form SSA-1280-U3-IT and/or SSA-1281-U3-IT for all survivors claims.
2. PART II.—Decision on claim/benefit amounts information
Until the supplemental agreement with Italy becomes effective, provide U.S. decisions on claims information on a liaison Form SSA-1279, SSA-1280 or SSA-1281 whenever a claimant under the agreement is either entitled to benefits on any SSN—regular or totalized—or disallowed for regular or for regular and totalized benefits—from the United States. Provide MBA or MBC (as appropriate) from November 1978 or from the claimant's MOEN, whichever is later whenever a claimant is entitled to benefits from the United States. Do not provide MBA information for months prior to November 1978.
b. Entitlement on another SSN involved
If a person—worker, spouse, widow or widower—is listed on a totalization application and is entitled to monthly Social Security benefits, send INPS monthly benefit information about that person without reference to entitlement on any other SSN.
Example 1—Mr. Rizzo listed Mrs. Rizzo on the application Form SSA-3954-F8 that he filed for benefits from Italy. Mrs. Rizzo is dually entitled to Social Security benefits: $220 as a spouse on Mr. Rizzo's SSN, and $180 as a worker on her own SSN. When completing the liaison Form SSA-1280-U3-IT, Item 3, make the appropriate entries under “To” and “From” and enter $220.00 under “Amount.” Do not refer to dual entitlement.
Example 2—Mr. Martini listed Mrs. Olive Martini on the application Form SSA-3954-F8 that he filed for benefits from Italy. Olive is not entitled on Mr. Martini's SSN because she is entitled to a higher benefit on her own SSN. When completing Form SSA-1280-U3-IT, Item 3, make the appropriate entries under “To” and “From” and enter the amount of Olive's monthly benefit(s) under “Amount.” Do not refer to Mrs. Martini's entitlement on her own SSN.
c. How to complete benefit amount information (Items 3 or 4 and 4.1 in Parts II, III and IV) when Italy requires it
If BETs check “2.a.,” “2.d.” or “2.c.,” benefit amount information is not applicable.
If BETs check “2.b.,” they must complete “3” as follows:
Under “From,” list the date(s) of entitlement for months beginning with 11/78 or date of entitlement to RSDI benefits, whichever is later.
Under “To,” list the last month(s) of the period(s) for which the benefit was payable.
Under “Amount,” list the monthly benefit amount(s) (MBA) payable for the periods shown to the left for periods prior to June 1982. For periods from June 1982 on list the monthly benefit creditable (MBC). If the amounts actually paid differ from the MBA and/or MBC due to withholding for either recoupment of an overpayment or to pay health benefit premiums, show the MBA or MBC. However, if the amount(s) actually paid differ from the MBA and/or MBC due to suspense or work deductions, show the amount(s) actually paid—if no benefits were paid, show “000” in parentheses immediately following the MBA. In the space to the right, explain the reason for the amount actually paid; e.g., “partial payment—work.”
Do not show the actual amount paid or make any additional entries if benefits were or are being withheld to recover an overpayment. Complete only the “To,” “From” and “Amount” columns for overpayment recovery cases.
If BETs check “2.c.” and the guaranteed minimum is not involved, they must complete “4.A.” as follows:
List the months under “From” and “To” as explained in b. above; and
Under part II, item 4.A., list the U.S. totalized MBAs and indicate amount(s) actually paid as described in 2.c. above.
If BETs check “2.c.” and the guaranteed minimum is involved, they must complete “4.” and “4.a. (A., B., C., D. and E.)” as follows:
List month(s) under “From” and “To” and list the U.S. totalization benefit(s) as described in 3.b.
Under B, list the Italian totalized benefit amount(s) for the period(s) shown to the left.
Under C, list the total(s) of the amount(s) shown immediately to the left.
Under D, list the U.S. minimum amount(s) for the period(s) shown to the left.
Under E, list the difference(s) between the amounts shown under “C” and the amount(s) shown under D; i.e., D minus C equals E.
3. Other claimant(s) information
Part IV, 1.c. of Form SSA-1281 requests information about other claimants. If the claimant is a child, determine the child's relationship from either the Form SSA-101-U3 or Form SSA-2417 (left-hand side of the RSDI folder). If the child is not or was never an RSDI beneficiary, show the child's relationship shown on the totalization application and check “alleged.” If evidence of birth or relationship; e.g., adoption papers, has been submitted, include it with the claims package.
C. Child(ren)'s attachment form for Germany (SSA-1281-U2)
The amount of a child's supplement paid by West Germany is cut in half if the child also receives a monthly benefit from the United States. Therefore, it is extremely important to notify the appropriate German agency about the entitlement of children to U.S. benefits. It is also extremely important to accurately report all nonpayment months to ensure that Germany does not halve a child's supplement for any month that child receives no benefits from the United States.
Therefore, when transmitting information and/or certifying data to West German agencies about children, transmit information about the decision on the child's claim for benefits.
This form is a 2 page snapout form.
Page 1 is printed in English. It is filed in the folder as documentation.
Page 2 is printed in German. It is sent to the appropriate German agency.
The information and verification blocks are completed on page 1. The entries correspond exactly to the information and verification blocks printed in German on page 2.
COMPLETE THIS FORM IN LEGIBLE BLOCK PRINTING, use a ball point pen to ensure the entries on page 2 are precise and dark enough to be easily read by the German agency personnel.
Enter dates in MM/DD/YY or MM/YY format.
Affix DIO stamp to bottom after completing the form.
b. Part I.—Certification of data
Enter first and last name of each child—one entry to each number (if there are more than 5 children claimants, use another form).
DATE OF BIRTH
Enter date of birth for each child listed. If child is an RSDI beneficiary, “X” verified block.
RELATIONSHIP TO WORKER
Enter each child's relationship to Number Holder. If this information is obtained from the Form SSA-101-U3 or Form SA-2417, “X” verified. If neither form is available, enter relationship alleged on the application. Do not “X” verified.
CITIZENSHIP STATELESS REFUGEE
See GN 01704.520.
Enter country of residence of the child, consult a CS or CATA if the country of residence cannot easily be identified.
c. Part II.—Decision on claim
Each entry in this part must correspond to the child listed with the corresponding number in part I.
“X” this block if the child has been entitled to RSDI benefits after November 30, 1979.
DATE OF ENTITLEMENT
Enter month and year child first became entitled to benefits after November 1979.
BASIS FOR ENTITLEMENT
“X” the basis for the child's entitlement. If a child has been entitled because he/she was under age 18 and also because he/she was a student or is disabled, “X” all appropriate blocks.
Enter all months for which the child received no monthly benefits from the United States. Check with a CS or CATA if there is any question about nonpayment months.
LAST MONTH OF ENTITLEMENT
Enter the month and year the child was last entitled to RSDI benefits, if the child has been terminated.
If a child's claim has been disallowed, “X” this block.
EXPECTED COMPLETION DATE
If no decision has been made on the child's claim for benefits, enter the month and year 6 months from the current date.
d. Transmitting form
Transmit the completed form to the appropriate German agency under cover of a Form SSA-e2960-U3-GE.
D. Swiss liaison certification forms (SSA-1279-U3-SZ, SSA-1280-U3-SZ and SSA-1281-U3-SZ)
Follow the preceding general instructions. In addition, Part IV, 1.c. of Form SSA-1281-U3-SZ requests information about the relationship of the child to the worker. If the child is or was an RSDI beneficiary and the RSDI folder is available, determine the child's relationship from the SSA-101-U3 or SSA-2417 on the left side of the folder. If the RSDI folder is not available and the source of information is an MBR, or if the child is or was not an RSDI beneficiary, show the child's relationship as shown on the totalization application and check “alleged.” If Switzerland needs more information, they will request it. If evidence of birth has been submitted with the totalization claim, include it in the claims package.