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  The date that you complete the form automatically propagates in the “DATE OF ORIGINAL” block.

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  FOLLOW-UP dates are automatically propagated.

Refer to GN 01708.025 to determine the proper office.

Complete the items in Part I as follows:

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  Item a) Always enter the first and last name of the worker.

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  Item b) Always enter the full name at birth.

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  Item c) Always enter the worker's U.S. Social Security number (SSN).

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  Item d) Always enter the worker's German Insurance Number if it is on the application or on the German liaison form.

  NOTE: The German number usually consists of twelve digits. The third through eighth digits represent the worker's date of birth in day, month, and year order. The ninth is an alphabetic character that represents the initial of the worker's last name at birth. The 12-digit number is often followed by a 4-digit suffix. The German Insurance Number is vital for the German agencies to locate the correct worker's record.

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  Item e) Enter the father’s name.

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  Item f) Enter the mother’s name.

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  Item g) Enter the name of claimant.

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  Item h) Enter the address of claimant.

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  Item i) In initial claims packages, enter the claimant's telephone number, including area code if it is shown on the application.

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  Item j) Enter the relationship to Worker.

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  In initial claims packages if the claimant is other than the worker, enter the claimant's relationship to the worker.

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  Item k) Select the types of benefits claimed. In all initial claims packages indicate the type of German benefits claimed.

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  Item l) Enter the date the claimant filed the claim with the agency for all initial claims packages or in response to a German agency's request for the filing date.

Complete the Certification of Data part of the form when transmitting a claim for German benefits. When replying to a German agency's request for specific information, complete only the specific items needed.

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  Item a) Date of Birth – Name(s) - Enter the first and last names of all claimants and if applicable, the maiden name. Enter the date of birth in month, day, and year format for all claimants named. Place of Birth column - For foreign-born workers, enter the name of the city, town, etc. followed by the name of the country.

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  For U.S. born worker, enter the city or town, the state, and “U.S.A.”

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  Item b) Date of Death - Enter the date of death if applicable.

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  Item c) Date of Marriage - Enter the date of marriage if applicable.

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  Item d) Date of Divorce - Enter the date of divorce if applicable.

NOTE: Verified Column- If you entered a date, check the “verified” block if we used the date to award U.S. benefits or the Master Beneficiary Record (MBR) or Numident show the date as proven. Otherwise, leave the “verified” block blank.

FSP personnel should not check “Verified” blocks.

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  Item e) Sex of Worker - Select M (male) or F (female) as appropriate for the worker.

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  Item f) Periods of Disability - Do not complete this block.

If a German agency requests information about a period of disability, refer the case to the DIO Division Analyst with your supervisor’s guidance.

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  Item g) Citizenship - Enter the alleged citizenship on initial claims packages and attach any evidence of citizenship to the form.

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  Item h) Country of Residence - Enter the country of residence on initial claims packages.

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  Item i) Benefit Data - If the worker, widow(er), or former spouse is entitled to a retirement insurance benefit (RIB) or disability insurance benefit (DIB) on this SSN, enter the effective date and the monthly benefit credit (MBC), as determined in GN 01708.320. If you identify a person as a widow, widower, or former spouse, enter the effective date and MBC of his or her own RIB or DIB, as determined in GN 01708.320 and check the Retirement or Disability block as appropriate.

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  Item j) If the Worker, widow, widower, or former spouse is entitled to Medicare Part A or Part B, check the appropriate boxes and enter the effective date.

If a widow, widower, or former spouse is not entitled to RIB or DIB on his or her own SSN, inform the German agency that the claimant is not entitled to retirement or disability benefits.

If we suspended or withheld benefits since the first month of entitlement, consult a Benefit Technical Examiner (BTE) or Claims Technical Examiner (CTE) to determine the reason and explain it to the German agency in Part V REMARKS section.

Check at least one block to indicate the type of material you are sending to the German agency.

Check the following.

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  Block A in initial claims packages to indicate that you attached an application for German Benefits (D/USA 1, or D/USA 2, or D/USA ZA).

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  Block B in initial claims packages and assistance requests to indicate that you attached a U.S. earnings record.

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  Block C and enter the date the information is requested on when responding to a German agency assistance request via form SSA-2960-GE.

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  Block D and enter the claimant's name when sending medical evidence in both initial claims packages and in response to requests.

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  Block E if the claimant alleged pre-57 military service but has not proven coverage (see GN 01707.210B.2.f.).

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  Block F (on assistance requests only) to indicate that there is no death certificate in our records. (Send requests for death certificates to an DIO Division Analyst).

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  Block G (on assistance requests only) to indicate that children's attachment form SSA-1281-U2GE is attached. (See GN 01708.245.)

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  Block H in both initial claims packages and assistance requests if attaching material not covered by any block shown above and briefly explain the attachment in Part V.

Check the appropriate blocks to indicate what information we are requesting from the German agency.

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  Do not check block A.

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  Check block B to request a German coverage record and indicate whether we need coverage records from January 1937 or January 1951, and the number of months of German coverage needed for insured status as instructed by the CTE.

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  Do not check block C.

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  Check block D when sending a follow up request and enter the date at the top. Also, see GN 01708.230.

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  Check block E if requesting other information and briefly explain the request in Part V.

Keep remarks to a minimum and make them clear and concise. Do not use technical jargon or abbreviations. Include specific remarks in the following situations.

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  If lag earnings have been alleged but not developed, enter “Earnings alleged for (year(s) of allegation). Please advise if you need U.S. coverage information for that period.” (See GN 01707.210B.2.f.)

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  If a German agency requested Medicare Part B (Supplemental Medical Insurance (SMI)) enrollment information, respond by entering “(name of beneficiary) is (or is not) enrolled in Medicare Part B.”