This form utilizes a unique generic numbering system for the specific items on the
form. Under this system the numbered item is usually shown on the form only if it
is pertinent to the specific case. For example, item 2.11 is designated as Date of
Marriage in the left hand column. If that date is known and is pertinent to the case,
it will be shown in the right hand column. If the date was immaterial or the person
never married, item 2.11 would either not appear on the form or would contain the
entry “none” or “not known” .
Some important things to know about the form:
The person's U.S. SSN appears as item 1.3, Your Reference Number and /or as item 3.3,
Your Insurance Number.
The Name of Worker is item 1.4.
If the date of an event (birth, marriage etc.) has been proven by documentary evidence,
the word “verified” will appear immediately after that date.
The “claim under the agreement” statement, which is usually required before we can release information under the
Privacy Act, can be found either in the “Liaison Details” or in the “Ad-Hoc Section.”