BASIC (04-09)

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.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0201750235
GN 01750.235 - Facts about the Czech Liaison Form CZ/USA 3 - 04/03/2015
Batch run: 04/03/2015
Rev:04/03/2015