Effective Dates: 10/18/2022 - Present Previous | Next

TN 4 (10-22)

GN 01749.215 Application for Benefits under the Czech Agreement

A. Filing for U.S. Totalization benefits

1. U.S. Totalization benefits only

An individual filing for U.S. Totalization benefits under the agreement with the Czech Republic must complete Part 1 of Form SSA-2490-BK, “Application for Benefits under a U.S. International Social Security Agreement,” and the appropriate retirement, survivors or disability insurance application.

2. U.S. Totalization and Czech benefits

An individual filing for both U.S. Totalization benefits and Czech benefits must complete the SSA-2490-BK (Part 1 only), the appropriate retirement, survivors or disability insurance application, and the special Czech application form (CZ/USA 202, “Claim for a Pension from the Czech Republic”) discussed in GN 01749.220.

3. Czech benefits only

An individual filing for Czech benefits only, completes the Czech application form (CZ/USA 202, Claim for a Pension from the Czech Republic). The individual does not complete Form SSA-2490-BK.

When an applicant files for fully insured (non-totalization) U.S. benefits and Czech Republic benefits (fully insured or Totalization), do not complete the Form SSA-2490-BK.

The Modernized Claims System (MCS) does not allow clearance of the claim for U.S. benefits until the CR enters the path for the SSA-2490. To clear the U.S. claim, the CR completes only the first (FINF) screen in the SSA-2490 path. This action releases the claim for U.S. benefits for award or denial. The CR completes the claim for Czech benefits using the Czech application form.

B. Claims Representative use of the SSA-2490-BK

Use the MCS version of the SSA-2490-BK only when the number holder (NH) is filing for

  • •

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

  • •

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

You must use a paper or electronic (e-form) SSA-2490-BK for Totalization survivor claims. Do not use the MCS version. When there is a previously approved Totalization life case award, it is not necessary to take an SSA-2490-BK in claims for U.S. auxiliary benefits in life cases or survivor cases, since this application would have been completed with the NH’s claim.

C. Required applications for U.S. Totalization benefits

When taking claims for U.S. Totalization benefits under the agreement with the Czech Republic, use the following information to determine which applications must be completed.

1. Retirement or Disability Claims

Complete retirement or disability claims using the appropriate MCS application screens, the Totalization (TOTL) screen (see MS 03509.011 ) and the SSA-2490 screens (see MS 03507.001 ).

2. Survivors Claims

Complete survivor claims using MCS application screens, the Totalization (TOTL) screen (see MS 03509.011), and Part I of the paper or electronic (e-form) Form SSA-2490-BK.

D. References

GN 01749.220, Additional Application Form for Czech Benefits

MS 03507.001, Introduction to SSA-2490 - Overview

MS 03509.011, Totalization (TOTL)

GN 01702.110, Application for Benefits Under a U.S. International Social Security (Totalization) Agreement (Form SSA-2490-BK)

GN 01702.310, Routing of Claims for U.S. Benefits Involving Totalization

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0201749215
GN 01749.215 - Application for Benefits under the Czech Agreement - 10/18/2022
Batch run: 10/18/2022
Rev:10/18/2022