BASIC (03-09)

GN 01749.220 Additional Application Form for Czech Benefits

A. Introduction

Form CZ/USA 202, Claim for a Pension from the Czech Republic, is used to take claims for Czech benefits (solely or with U.S. Totalization) from persons filing the application in a field office (FO). This section explains how to download the application form and how to take a claim for Czech benefits using the Czech application form.

B. Claims Representative takes required application for Czech benefits

If an applicant files for Czech benefits:

  1. Access the Totalization Benefits Resource Kit on the intranet at

  2. Print the Czech application form (CZ/USA 202) and instructions. Give them to the applicant for completion.

  3. Provide assistance in completing the Czech form.

  4. Request an “Informational/Certified Earnings Record” (ICERS) per MSOM ICERS 001.004.

  5. Photocopy, stamp, and sign evidence submitted by the applicant.

  6. Send the completed Czech application form, certified copies of evidence, and certified earnings record (ICERS) to the Office of International Operations (OIO) in Baltimore at the following address:

    Social Security Administration
    OIO – Totalization
    P.O. Box 17769
    Baltimore, Maryland 21235-7769

    NOTE: OIO sends the claim to the Czech agency with the evidence and the worker’s U.S. coverage record.

  7. Complete the Modernized Development Worksheet (MDW) screen showing the date you sent the Czech claim to OIO. Show “Totalization” as the ISSUE when completing the MDW screen.

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GN 01749.220 - Additional Application Form for Czech Benefits - 03/12/2009
Batch run: 03/12/2009