GN 01726.105 Dutch Coverage Certification
The only acceptable form for the certification of Dutch coverage is the NL/ VS 205. Route certifications in any other format to CPS. The form is usually sent under cover of liaison Form, NL/VS 3.
B. Description of form NL/VS 205
The following is a description of Form NL/VS 205.
The upper part of the NL/VS 205 contains a space for entering the U.S. SSN, if known.
Part 1 contains all necessary identifying information about the insured person and is self-explanatory.
Part 2 contains periods of creditable Dutch coverage in the European style, i.e. day, month, year.
“From-to” periods will often span many years.
The number of months of coverage in a period are not reflected. However, all periods of Dutch coverage are continuous periods, i.e. all months within a given “from-to” period are coverage months.
If there is a break in coverage, a new period identified by a new beginning date is shown.
Records certified by SVB contain coverage information beginning with January, 1957 or the first month of coverage, if later.
Records certified by UWV contain coverage information beginning with July, 1967 or the first month of coverage, if later.
A provisional record can be recognized by the word “provisional” written somewhere on the form or by the appearance of coverage periods which are later than the date the form was completed. (See GN 01726.115 for a discussion of provisional records.)
The agency which issued the record is indicated at the bottom of the form, in the event that additional information or explanation are required.
C. Exhibit of form NL/VS 205
VERDRAG INZAKE SOCIALE ZEKERHEID TUSSEN HET KONINKRIJK DER NEDERLANDEN EN DE VERENIGDE STATEN VAN AMERIKA AGREEMENT ON SIOCIAL SECURITY BETWEEN THE KINGDOM OF THE NETHERLANDS AND THE UNITED STATES OF AMERICA
Aan/To Social Security Adminstration U.S.A.
U.S. Social Security Number
Verklaring over Nederlandse verzekeringstijdvakken betreffende:
Certification of Netherlands creditable periods concerning:
Date of birth dag/day maand/month jaar/year
Place of birth
Netherlands employee security number
Netherlands social security number
In Nederland/In the Netherlands
( )Social Insurance Bank ( )Gemeenschappelijk Administratienkant ( )Bedrijfsvereniging
(handtekening/signature) (datum/date) stempel/stamp