The Disability Liaison Form is a 3-part form which is completed in DIO.
Part I contains general information about the claimant's onset and work cessation.
Part II contains information which allows France to offset a French invalidity benefit
against any U.S. disability benefit being paid.
Part III contains information which notifies France if a U.S. disability beneficiary
has been terminated and the reason for that termination.
Follow these instructions to complete the items on the form.
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.
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
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.”
Enter the date the worker alleges that his/her disability first made him/her stop
If the worker is still working, enter “Still Working.”
If there is no allegation in the file, enter “Unknown.”
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.”
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.”
If the worker has stopped working, check the appropriate block and enter the date
his work ceased.
If the worker was an employee, enter the type of work he/she performed; e.g., carpenter,
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.”
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.”