The Transmittal/Request/Certification form is the cover sheet of packages and requests
prepared for foreign agencies in Norway and Belgium. As the name suggests, it is a
multipurpose form used to transmit information and material to foreign agencies, to
request information and material from foreign agencies and to certify information
as verified when that information has been used to adjudicate a claim for benefits
from the United States.
It is a two-page form consisting of the original (blue) and a file copy (white). The
top section of the forms displays the foreign agency names and addresses on the left
and DIO's totalization address on the right.