GN 01750.012 How the Foreign Service Post in Warsaw, Poland Processes and Develops Claims Filed With the Czech Republic Agency
When a person not eligible for Czech benefits contacts the Czech Republic agency, CSSZ to file a claim for U.S. benefits, CSSZ sends the following information to the FSP in Warsaw, Poland:
SSA-2490-BK (Application for Benefits under the U.S. International Social Security Agreement) and Supplemental Questionnaire (This form can be located on the Division of International Operations website).
A liaison form, SSA-e2960-U3-CZ(Transmittal/Request/Certification Form-CZ/USA3), certifying the filing date for the claim.
Czech certified coverage record (CZ/USA205)
Available medical evidence if the claim is for disability benefits.
This procedure explains how the FSP in Warsaw, Poland should process referrals from CSSZ.
1. Claimant entitled to U.S. benefits
Forward all material to DIO annotated “already entitled to U.S. benefits”.
2. Claimant not entitled to US benefits
Process the claim in the same manner shown in GN 01750.010B.
MSOM MCS 009.011 TOTALIZATION (TOTL)