Form SSA-2490-BK (Application for Benefits under a U.S. International Social Security Agreement) is available through MCS. The MCS version of Form SSA-2490-BK is an option for filing only when the number holder (NH) is filing for:

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  U.S. retirement or disability Totalization benefits only; or

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  U.S. retirement or disability benefits (regular or Totalization) and concurrently for Luxembourg benefits.

Do not use the MCS version of the SSA-2490-BK to file an application for:

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  Luxembourg benefits only; or

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  U.S. or Luxembourg survivor benefits.

Use a paper or electronic Form SSA-2490-BK for Totalization survivor claims. For instructions to complete the SSA-2490-BK, see GN 01702.110.

NOTE: It is not necessary to take an SSA-2490-BK in claims for U.S. auxiliary benefits in life cases or in survivor cases where there was a previously approved award in a life case, since the NH previously completed the form in connection with their application for benefits. The MCS version of the Form SSA-2490-BK may not be used to file for U.S. Totalization survivors benefits. A paper or electronic Form SSA-2490-BK must be used in this case. For further information see MS 03509.011.

Use the following information to determine the application screens to complete when taking claims under the Agreement with Luxembourg for U.S. Totalization or Luxembourg benefits.

Along with the Form SSA-2490-BK, an applicant for Luxembourg benefits under the U.S. - Luxembourg Agreement must complete one or more special Luxembourg application forms. The form(s) required vary depending on the type of benefit claimed.

SSA Field Offices (FO) do not generally accept special Luxembourg application forms.

After receiving an application for Luxembourg benefits filed with SSA, the Luxembourg agency mails the appropriate Luxembourg application forms to the applicant. The Luxembourg agency instructs the applicant to complete the forms and mail them directly to the Luxembourg agency with any required evidence.

If an applicant brings a Luxembourg special application form(s) (or Form SSA-2490-BK) to the FO, the FO should:

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  Complete the appropriate MCS application screens for retirement, disability or survivors’ benefits; and

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  Complete the TOTALIZATION (TOTL) screen (see MSOM MCS 009.011); and

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  Photocopy and certify any additional documents (evidence) the Luxembourg agency requested the applicant to include with the Luxembourg claim; and

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  Request an "Informational/Certified Earnings Record" (ICERS) as described in MS ICERS 02101.004; and

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  Process the insured-status in accordance with GN 01702.315; and

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  Return to the applicant any original evidence documents and the certified photocopy of the application; and

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  Send the original Luxembourg application and any certified photocopies or additional claims material to the Division of International Operations (DIO) in Baltimore at the following address:

  Social Security Administration

  Division of International Operations

  P.O. Box 17769

  Baltimore, Maryland 21235-7769

  FAX number: 410-966-1861

  NOTE: If courier service is used, mail to:

  Social Security Administration

  Division of International Operations

  6100 Wabash Avenue

  Baltimore, Maryland 21215

Once DIO receives the claim, they will send the claim directly to the Luxembourg agency along with the evidence and the worker's U.S. earnings record. DIO will annotate the MDW to show the type of claim and the date they forwarded the claim to the Luxembourg agency. When DIO receives the Form SSA-2490-BK, they will send a notice to the applicant explaining this requirement to file another application and referring the applicant to the nearest Luxembourg consulate or the Luxembourg Embassy if necessary. If the applicant is a non-Luxembourg citizen, advise the applicant that DIO will mail another application form to them to complete and return to DIO.