• •

  Page 1 (File copy)-this page is printed in English and is used for folder documentation.

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  Page 2 (First Request)-this page is printed in French and is the initial copy sent to C.N.A.V.T.S.

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  Page 3 (Follow-up)-this page is printed in French and is used as a follow-up request, when necessary.

Complete this form to request or transmit information to France, except in the following situation.

EXCEPTION: If a French agency has requested earnings information using their liaison form, reverse the “TO” /“FROM” block on that form and use it to send the response.

Follow this table to complete the items on the form.

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  Complete this section in its entirety if you are sending an initial claim to France.

• •

  Complete items 1-4 and 9-11 if you are requesting a French coverage record or other information in connection with a U.S. only claim.

• •

  Complete items 1-3, 9 and 10 if you are responding to a request from France and not using this liaison form as a transmitting document.

• •

  Check verified if an item has been established in connection with a claim for U.S. benefits.

  NOTE: Most items are self-explanatory.

  If the claimant has submitted original documents in support of his/her claim, prepare certified photocopies or send the original according to the claimant's wishes.

  If the claimant submits a Certification of Civil Status which they have obtained at a French Consulate, include that document in the package.

• •

  Enter the French enrollment number in item 9. If unknown, enter “Unknown” . However, if the French enrollment number is unknown, attach a separate sheet of paper showing as much of the following information as is available:

  1. a. 

     Date of birth, if not shown in item 4.

  2. b. 

     Place of birth, if not shown in item 4.

  3. c. 

     Father's name.

  4. d. 

     Mother's maiden name.

• •

  Enter in item 10 the U.S. SSN. If unknown enter “Alpha.”

• •

  Enter in item 11, information about the worker's last job in France.

  1. a. 

     Type of job—Enter the type of job held by the worker; e.g., baker, carpenter, etc. If worker was self-employed, enter “Self-employed” followed by the type of work: e.g., farmer, doctor, etc.

  2. b. 

     Place of employment—Enter the town or city where the worker was last employed or self-employed.

REMINDER: You should enter “unknown” in these spaces only when the claimant has been asked these specific questions and is unable to supply the information.

• •

  Complete this section only if you are sending a claim for French benefits. (Most items are self-explanatory.)

• •

  Check verified if an item has been established in connection with a claim for U.S. benefits.

• •

  If the claimant has submitted original documents in support of his/ her claim, prepare certified photocopies or send the original according to the claimant's wishes.

• •

  If the claimant submits a Certification of Civil Status which they have obtained at a French Consulate, include that document in the package.

• •

  Enter in item 6, the spouse's French enrollment number. If unknown, enter “Unknown.”

• •

  However, if the spouse states that an enrollment number was issued but is unknown, enter as much of the following information as is available.

  1. a. 

     Date of birth, if not shown in item 4.

  2. b. 

     Place of birth, if not shown in item 4.

  3. c. 

     Father's name.

  4. d. 

     Mother's maiden name.

• •

  Complete this section only if you are sending a claim for French benefits. (Most items are self-explanatory.)

• •

  Check verified if an item has been established in connection with a claim for U.S. benefits.

• •

  If the claimant has submitted original documents in support of his/ her claim, prepare certified photocopies or send the original according to the claimant's wishes.

• •

  If the claimant submits a Certification of Civil Status which they have obtained at a French Consulate, include that document in the package.

• •

  Enter information for up to 3 children. If more space is needed, enter information about additional children on a supplemental form SSA-e2960-U3-FR.

Complete this block. Also, include the telephone number when available in the appropriate space.

Always check at least one of the following blocks in this section.

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  None—Check this block if you are requesting, but not providing, information.

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  Coverage Record—Check this block if you are attaching a U.S. coverage record.

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  Medical File—Check this block if you are attaching medical evidence submitted by the claimant, copies of medical evidence from SSA's files or form SE-404-4.

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  Disability Attachment—Check this block if you are attaching a disability liaison form (USA/FR 3a).

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  Status of Request Dated—Check this block if you are giving the status of a request for information from France. Enter the date of their request.

• •

  Other—Check this block if you are attaching material, other than a claim, not covered by any block shown above; e.g. a work history statement, documents submitted by the claimant, or benefit amounts. Briefly explain your attachment.

  NOTE: France needs to know the amount of a person's own RIB or DIB if they are entitled to a French survivor's benefit. France will go directly to the claimant first for this information.

  If the beneficiary is unable to provide adequate information, the French agency may request the information from DIO using an English language letter attached to Form SE-404-03. If this happens, enter the claimant's own retirement benefit amount.

  Use this block to enter the 11 digit French reference number. This number is generally shown on the blue sticker France puts on their correspondence and should always be shown if it is known.

Check the box in the top section indicating whether the requested information is in connection with a claim under the agreement.

If “NO,” be sure to attach a signed authorization statement from the claimant. In the lower section, always check at least one of the following blocks.

• •

  None—Check this block if you are providing, but not requesting, information.

• •

  Coverage record—Check this block if you are requesting a French coverage record.

• •

  Medical file—Check this block if you are requesting a copy of medical evidence contained in the French file.

• •

  Disability Attachment—Do not check this block. (We never request the French disability attachment.)

• •

  Status of Request Dated—Check this block if you want to know the status of an earlier request. Show the date of the request and attach a copy.

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  Other—Check this block if you are requesting information not covered by a block shown above. Briefly explain your request.

Affix the DIO stamp in this area. Be careful not to obliterate the check blocks in Section V.