GN 01750.235 Facts about the Czech Liaison Form CZ/USA 3
A. Procedure – When form CZ/USA 3 will be used
CSSZ will use the form CZ/USA3 to:
Transmit material to OIO or to the FSP in Warsaw.
Send information to OIO or to the FSP in Warsaw.
Request information from OIO.
B. Form CZ/USA 3 – Transmittal/Request/Certification
The SSA-2960 CZ/USA 3 may be printed from the SSA Totalization Forms section of the Totalization Resource Kit .
C. Description of the form CZ/USA3
1. Part 1
Part 1 contains information about the claim and the claimant.
2. Part 2
Part 2 contains certification of data. If verified, the appropriate block is checked.
3. Part 3
Part 3 contains information provided by the Czech agency, including medical evidence in disability claims.
4. Part 4
Part 4 contains a list of the type of information that the Czech agency might request from OIO and/or FSP in Warsaw Poland along with the remark that the information is needed to process a claim under the agreement or that a consent statement is attached.
5. Part 5
Part 5 contains any necessary remarks.