GN 01750.010 How to Develop and Process Applications Filed in the Foreign Service Post in Warsaw, Poland
The Foreign Service Post (FSP) in Warsaw, Poland will forward requests to the Czech Republic agency, CSSZ and CSSZ will send the FSP the required documents needed to process the claim
When processing claims under the agreement, the FSP should follow the same general procedures and obtain the same applications and evidence as SSA field offices.
This procedure describes special development and routing instructions that apply to claims under the agreement filed in Warsaw, Poland.
1. U.S. claim
a. Retirement, survivors, and disability claims
The FSP in Warsaw, Poland will forward all requests to CSSZ.
The CSSZ agency will send the following information to the FSP in Warsaw, Poland:
a liaison form, SSA-e2960-U3-CZ (Transmittal/Request/Certification Form- CZ/USA3), certifying the filing date and the established factors of entitlement.
a Czech certified earnings record (CZ/USA205)
any available medical evidence if the claim is for disability,
a SSA-2490-BK (Application for Benefits Under a U.S. International Social Security Agreement) and Supplemental Questionnaire (This form can be located in the Division of International Operations website).
For retirement and disability claims, complete the appropriate MCS application screens and the TOTALIZATION (TOTL) Screen (see, MSOM MCS 009.011) and SSA-2490 screens (MSOM MCS 007.001).
b. Survivor claims
Complete the appropriate MCS application screens
Complete the Totalization (TOTL) screen (see MSOM MCS 009.011)
Complete Part 1 of the paper or electronic (e-form) application, Form SSA-2490 BK (Application for Benefits under the U.S. International Social Security Agreement) – Worker appears not to be insured based on U.S. coverage alone requesting Czech coverage record.
Forward a liaison form, SSA-e2960-U3-CZ (Transmittal/Request/Certification Form-USA/CZ3), to CSSZ to request the Czech certified coverage record if it appears that the worker is not insured based on U.S. coverage alone.
c. Claim to DIO
Forward the claim to DIO and include a copy of the completed liaison form sent to CSSZ.
2. Czech claim
Refer any inquiries for Czech benefits from a resident of the Czech Republic received in the FSP in Warsaw, Poland or in the U.S. Embassy in the Czech Republic to the CSSZ.
If CSSZ needs U.S. certified earnings record and/or entitlement information to process a claim for Czech benefits, it will request the information directly from the FSP in Warsaw, Poland using a liaison form, SSA-e2960-U3-CZ (Transmittal/Request/Certification Form-CZ/USA3).