Make entries next to the dates in Sections 1 and 6 only if SSA has established the
relevant date in connection with a concurrent retirement, survivors or disability
claim, or the date was previously established in connection with a prior claim and
the date is available from the master beneficiary record (MBR). When an alleged date
has been proven for SSA purposes, check the box beside “AS STATED.” If SSA has established a date different than the one alleged by the claimant, check
the box next to the blank line and enter the proven date on the line. The proper date
should be entered in year, month, and day order. (EXAMPLE: if the date of birth is January 2, 1935, enter 1935/Jan/02.) If SSA has not established
an alleged date, make no entry by that date. If any entries are made next to the dates
in Section 6, enter your initials in the “VERIFIED BY:” space.
Note: When a designated border office or OIO indicates in Section 1 or 6 that a particular
factor has been established for SSA purposes, it is not necessary to send to the Canadian
agency photocopies of evidence used to establish that factor.