TN 6 (10-03)
GN 01715.230 Completion of Application for Quebec Pension Plan Benefits Under the Quebec - United States of America Social Security Understanding (QUE/USA-1)
The QUE/USA-1 application form is available through the Intranet at http://eis.ba.ssa.gov/eis/misc/resource-kits/resourcekits.htm and is used to claim benefits from the Quebec Pension Plan (QPP). The form is in a bilingual English and French format.
B. Procedure - Entering dates on Quebec application form QUE/USA-1
Enter dates on the QUE/USA-1 as follows:
enter the date in year, month, day order (or, where applicable, year, month order)
print the first 3 letters of a month rather than its numerical equivalent.
Example: If the date of birth is January 2, 1935, enter 1935/Jan/02.
C. Procedure - Completing Quebec application form QUE/USA-1
Use the following information to complete those items on the Quebec application form QUE/USA 1 that are not self-explanatory.
1. Part A - General Information About the Contributor
Complete Part A in all claims for QPP benefits. Include general information about the worker (contributor).
Item 1 - Check either French or English even if the applicant has no preference. If the last Canadian province in which the worker lived was Quebec, the QPP has jurisdiction; otherwise, the Canada Pension Plan (CPP) has jurisdiction and the applicant should complete the CDN-USA 1 rather than the QUE/USA-1.
Item 7 - If separated, enter the date the worker and the spouse began living apart, regardless of whether legally separated at the time.
Item 10 - Include natural, adopted or stepchildren of the worker, regardless of age or marital status of the children.
2. Part B - Application for a Retirement Pension
Complete Part B if the applicant is applying for a retirement benefit.
3. Part C - Application for Disability Benefits
Complete Part C if the applicant is applying for a disability benefit.
4. Parts D and E - Application for Survivors' Benefits
Complete Parts D and E if the applicant is applying for survivor's benefits.
5. Part F - Declaration of the Person Making the Application
Complete Part F in all claims for QPP benefits. The applicant must sign and date the application.
Where the applicant signs by mark, the signature must be witnessed.
If the application is signed in the presence of an SSA employee, the SSA employee may sign as witness and enter the field office (FO) address.
6. Part G - This Part is to be Completed by the Competent Institution of the United States of America
This section is completed only by staff in the Office of International Operations (OIO) or one of the designated border offices (at the Claims Representative level or higher) identified in GN 01715.320. It informs the Quebec agency which, if any, of the eligibility factors shown have been verified for SSA purposes.
Always enter the date claim filed in the first block. This date will be the date of filing in the FO or an earlier protective filing date, if applicable.
Make entries in the remaining blocks only if the relevant date has been established for SSA purposes either in connection with a
concurrent retirement, survivors or disability claim, or
prior claim and the date is available from the master beneficiary record (MBR).
For each date established by SSA, enter the date in the appropriate space and check the “Verified” box. (The date that has been proven for SSA purposes is entered even if different than the alleged date.)
If SSA has not established a particular date, make no entry.
When surviving spouse's benefits are claimed, enter the surviving spouse's name and date of birth (if established for SSA purposes) in the appropriate space and check the “Verified” box.
Enter any children's names and dates of birth (if established for SSA purposes) in the appropriate spaces and check the “Verified” box.
Enter the name and address of the office in the space designated “Name of the Institution” (e.g., SSA field office, Burlington, Vermont).
Sign and date in the space provided and also print the name and title of the individual completing this section.
Stamp the section in the space provided with the date stamp used to date stamp applications for U.S. benefits.