BASIC (08-94)

GN 01726.235 Facts about the Dutch Liaison Form NL/VS 3

A. Process

The Dutch agencies use liaison form NL/VS3 to:

  • transmit material to DIO or the FSPs in London and Dublin

  • send information to DIO or the FSPand

  • request information from DIO

B. Exhibit of form NL/VS3 (English version)

 


NL/VS 3

NETHERLANDS/USA AGREEMENT ON SOCIAL SECURITY

To:

( )

Social Security Administration
Office of International Operations
P.O. Box 17049
Baltimore, Maryland 21235
U.S.A.

From:

 

( )

U.S. Embassy, FBU, 42 Elgin Rd, Ballsbridge, 4 Dublin, IRELAND

 

  1. INFORMATION ABOUT THE CLAIM

  1. Name of worker

  1.   

    
  1. Dutch Social Insurance Number

  1.  

    
  1. U.S. Social Security Number

  1.  

    
  1. Type of Claim

 

U.S.

Dutch

 
  1. old age

    survivor

    disability

  • ( )

    ( )

    ( )

  • ( )

    ( )

    ( )

  1. Date of Claim

  1.  

 
  • day

month

year

  1. Name and Address of Claimant

  1.  

  1. VERIFICATION OF INFORMATION

    1. The Worker

 day/month/yearverified
full name at birth               
date of birth           ( )
date of death          ( )


NL/VS 3

b.  Spouse or Widow(er)day/month/yearverified
full name               
   

date of birth

 

( )

date of marriage

 

( )

date of divorce

 

( )

 

c.  Childrendate of birth
day/month/year
verified

Name        

 

( )

Name        

 

( )

  1. MATERIAL ATTACHED

    1.  ( ) No Material

    2.  ( ) Dutch Insurance Record (NL/VS 205)

    3.  ( ) Medical Evidence

    4.  ( ) Information Requested on                     


      day/month/year                                

    5.  ( ) Other (see remarks)

  1. INFORMATION REQUESTED FROM U.S.A.
    This information is needed to process a claim under the
    agreement.   ( )Yes    ( )No

    1.  ( ) No Information Needed

    2.  ( ) Entitlement moneth and benefit amount for:      

    3.  ( ) US Insurance Record

    4.  ( ) Medical Evidence

    5.  ( ) Status of Request Dated           day/month/year

  1. REMARKS

     


STAMP      

  
Signature of SVB/SWV EmployeeDate

C. Description of form NL/VS3

  • Part 1 (INFORMATION ABOUT THE CLAIMS) contains general information about the claim including, if known, the U.S. SSN

  • Part 2 (VERIFICATION OF INFORMATION) contains spaces for the Dutch agencies to indicate the claimants' names, dates of birth and other event dates and to indicate whether these dates have been verified by acceptable evidence.

  • Part 3 (MATERIAL ATTACHED) contains information from the Dutch agency that indicates whether evidence is attached.

  • Part 4 (INFORMATION REQUESTED FROM USA) contains a list of the types of information that a Dutch agency might request from DIO. A check in block b., “an agreement claim has been made” constitutes authority to disclose information to the Dutch in the absence of a signed U.S. application form SSA-2490, Dutch application form NL/VS 202 or 203 or other signed statement.

  • In the REMARKS portion the Dutch agencies often ask for a form “VS/ NL 205” . Such a form does not exist, however, in these instances the Dutch agencies are really requesting a U.S. earnings record.

  • A Dutch agency's request for a “copy of the decision” means that they want to know the claimant's month of entitlement to U.S. benefits and the monthly benefit amount. See GN 01726.220.D.4


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0201726235
GN 01726.235 - Facts about the Dutch Liaison Form NL/VS 3 - 01/18/2017
Batch run: 01/18/2017
Rev:01/18/2017