BASIC (10-93)

GN 01724.225 Completing the Disability Liaison Form (USA/FR 3a) (SE 404-3a)

A. Description of form USA/FR 3a

The Disability Liaison Form is a 3-part form which is completed in DIO.

1. Part I

  • Part I contains general information about the claimant's onset and work cessation.

2. Part II

  • Part II contains information which allows France to offset a French invalidity benefit against any U.S. disability benefit being paid.

3. Part III

  • Part III contains information which notifies France if a U.S. disability beneficiary has been terminated and the reason for that termination.

B. Procedure

Follow these instructions to complete the items on the form.

1. When to complete

  • If the worker is a U.S. resident and is claiming disability benefits from France, complete Parts I and II.

  • If the worker is a French resident and the French liaison agency or a French local agency requests information about entitlement to U.S. disability benefits, complete only Part II.

  • If the worker is a U.S. disability beneficiary or was a U.S. disability beneficiary whose disability benefits have stopped and a French agency requests information about the current status, complete only Part III.

2. How to complete

Follow the table in 3. below to complete the items on the form.

Make all entries in legible block printing.

NOTE: This form does not require a certification separate from that on the covering form SSA-e2960-U3-FR.

3. Parts of form

a. Pt. I information on the disability

 

ItemAction

1.1

  • If there is a completed (Form SSA-831) in a file in DIO, enter the established onset date found in item 15a.

  • If there has been no SSA decision on a claim for U.S. disability benefits, enter the alleged onset date shown on the disability application.

  • If there is no U.S. disability application available, show “Unknown.”

1.2

  • Enter the date the worker alleges that his/her disability first made him/her stop working.

  • If the worker is still working, enter “Still Working.”

  • If there is no allegation in the file, enter “Unknown.”

1.3

Self-explanatory

1.4

  • If the worker is still employed, enter the employee's salary, if known, and state whether it is a yearly, monthly or weekly amount.

  • If the worker's salary is not known, show “Unknown.”

1.5

  • If the worker is still self-employed, enter the net earnings from self-employment for the most recent year. If figures are not in file show “Unknown.”

  • Enter the type of self-employment; e.g., doctor, farmer, etc. If the worker's profession is unknown, enter “Unknown.”

1.6

If the worker has stopped working, check the appropriate block and enter the date his work ceased.

1.7

If the worker was an employee, enter the type of work he/she performed; e.g., carpenter, salesclerk, etc.

1.8

Enter the amount and type of any other income the worker receives; e.g. pension, workman's compensation, etc. If other sources of income are not known, enter “Unknown.”

1.9

If known, check the appropriate blocks to show if the worker's disability was caused by a third party, resulted from a work-related accident or occupational disease or accident. If this information is not known, enter “Unknown.”

b. Pt. II information relating to the calculation of disability benefits

 

ItemAction
2.1Check this block and fill in the remaining information if the worker is entitled to U.S. disability benefits.
2.2Check this block if the worker's U.S. disability claim has been denied. Enter the reason for the denial on the lines provided. Do not check this block if an initial Title II denial has been processed but a totalization disability claim is still pending.
2.3Check this block and fill in the remaining information if a U.S. disability claim, regular or totalization, is still pending.
2.4Check this block and fill in the remaining information if the worker is receiving any other type of disability related benefits; e.g., private disability pension, workmen's compensation, unemployment benefits, etc. If there is no information in the file about entitlement to other benefits, enter “Unknown.”

c. Pt. III post-adjudicative status of the disabled worker

 

ItemAction
3.1Check the appropriate block to show whether the worker is entitled to disability benefits. If the worker is no longer entitled to benefits, check the appropriate block to show why the entitlement ended.
 
If the worker began working again, show the date he/she returned to work.
3.2If the worker returned to work as an employee, enter the type of work being performed and the amount of monthly wages in the last quarter in dollars.
3.3If the worker returned to work as a self- employed person, enter the type of work performed and the monthly, quarterly or yearly income in dollars.
3.4Enter here any additional information you want to include on the form.

C. Exhibit

 

G-SE-404-3A-1

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G-SE-404-3A-2

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G-SE-404-3A-3

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G-SE-404-3A-4

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To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0201724225
GN 01724.225 - Completing the Disability Liaison Form (USA/FR 3a) (SE 404-3a) - 03/23/2017
Batch run: 03/23/2017
Rev:03/23/2017