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.

If an applicant files for Czech benefits:

1. 1. 

   Access the Totalization Benefits Resource Kit.

2. 2. 

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

3. 3. 

   Provide assistance in completing the Czech form.

4. 4. 

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

5. 5. 

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

6. 6. 

   Send the completed Czech application form, certified copies of evidence, and certified earnings record (ICERS) to the Office of Earnings and International Operations (OEIO)/Division of International Operations (DIO) in Baltimore at the following address:

   Social Security Administration
   OEIO/DIO
   P.O. Box 17769
   Baltimore, Maryland 21235-7769

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

7. 7. 

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