The top section contains identifying information about the number holder and the identity of the sender. These forms are completed in selected district offices (see GN 01715.320) as well as in INTPSC. INTPSC personnel should always “X” the INTPSC address block on the right-hand side of the form.

The addresses of the Canadian agencies are preprinted on the form. Check the appropriate block(s) to indicate to which agency(ies) the information or request is directed. There are times when both blocks are checked; e.g., the applicant has filed for both OAS and QPP benefits.

This section is self-explanatory. Place an “X” in all applicable blocks.

Check item A or at least one of the other items. Do not routinely request medical evidence contained in Canadian agency files. If a Canadian coverage certification is needed and you are sending a claims package to a Canadian agency because the person has filed for Canadian benefits, request the coverage certification from the agency. If the person has filed for both OAS and QPP benefits, request the coverage certification from the QPP. If the person is filing for U.S. totalization only, determine the office with jurisdiction by referring to GN 01716.210.

Check all applicable blocks to indicate the social insurance system(s) from which the person has claimed benefits. If Form SSA-1294-F5 was completed, check United States. If Form CAN/USA 1 was completed, check Canada. If Form QUE/USA 1 was completed, check Quebec. Do not complete this block when responding to assistance requests.

Place an “X” in the appropriate block(s) to identify the type(s) of benefits being claimed from Canada. This information can be found on the CAN/USA 1 (Section 1, Questions 2), the QUE/USA 1 (Part II) and the SSA-1294-F5 (Question 2). Do not complete this block when responding to assistance requests.

This is a three-page snapout form consisting of the original (blue), an Ottawa copy (yellow) and a Quebec copy (white). The original is filed in the totalization folder and serves to document the action taken. The Ottawa copy is used to furnish information to or request information from Ottawa. If it is not used, it should be destroyed. The Quebec copy is used to furnish information to or request information from Quebec. If it is not used, it should be destroyed.

Diary initial requests to the Canadian agencies for 90 days. Diary all status requests for 60 days. If no response has been received at the end of the second status request diary period, forward the case to TOAB.