TN 3 (10-22)

GN 01751.220 Additional Application Forms for Polish Benefits

A. Introduction to special Polish application forms

In addition to Form SSA-2490-BK (Application For Benefits Under a U.S. International Social Security Agreement), an applicant for Polish benefits may need to complete one or more special Polish application forms. The form(s) to be completed vary depending on the type of benefit claimed.

B. Process for forms from ZUS or KRUS (PL/USA 4)

The Polish application forms from ZUS or KRUS (PL/USA 4) can be printed in the field office (FO) from the SSA Totalization Forms section of the Totalization Resource Kit and given to or mailed to the applicant for completion. Completion and mailing instructions are provided with the forms. The forms are to be sent to either ZUS or KRUS. If the claim for Polish benefits was filed with SSA and additional information is needed by the Polish agency, the Polish agency will mail the applicant any additional forms for completion and instruct the applicant to mail the additional evidence directly to the Polish agency.

C. Procedure — Applicant brings a Polish application to the FO

If an applicant brings one of the Polish application forms to the FO, the FO should:

  1. 1. 

    Provide any necessary assistance in completing the form(s).

  2. 2. 

    Photocopy and certify any documents (evidence) the Polish agency has requested the applicant to include with the Polish claim.

  3. 3. 

    Return the form(s) and certified photocopies to the applicant and the applicant to mail them directly to Poland at the address shown in the instructions on the form.

  4. 4. 

    Advise the applicant to check with the U.S. Postal Service for the international rate and/or fee for mailing materials to Poland.

REMINDER: Do not mail the forms to the Office of International Operations (OIO).

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GN 01751.220 - Additional Application Forms for Polish Benefits - 10/18/2022
Batch run: 10/18/2022