TN 1 (03-97)

GN 01714.235 Facts about the Belgian Liaison Form

A. Policy

The transmittal/request Form BE/USA 3 is the agreed upon form for a Belgian agency to:

  • transmit material to DIO or the FSP in Brussels,

  • send information to DIO or the FSP, and

  • request information from DIO.

B. Description of form BE/USA 3

The Form BE/USA 3 is printed in Flemish or in French. The Exhibit shown in the next section contains an English translation of all items on the form. Following is a description of the items on the Form BE/USA 3:

  • Part I contains general information about the claim.

  • Part II contains information about the worker and claimants.

  • Part III provides information about material that the Belgian agency is transmitting with the liaison form.

  • Part IV lists the information that the Belgian agency is requesting from SSA. This section includes a Privacy Act authorization to release information to Belgium.

  • Part V contains remarks.

C. Exhibit - Belgium - U.S. agreement on social security transmittal /request /certification - BE/USA 3


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GN 01714.235 - Facts about the Belgian Liaison Form - 06/15/2017
Batch run: 06/15/2017