GN 01752.235 Facts about the ZUS or KRUS Liaison Form PL/USA 3
A. Procedure – When Form PL/USA 3 Will Be Used
ZUS or KRUS will use the form PL/USA3 to:
B. Form PL/USA 3 – Transmittal/Request/Certification
Description of the Form PL/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 will be checked.
3. Part 3
Part 3 contains information provided by the ZUS or KRUS agency, including medical evidence in disability claims.
4. Part 4
Part 4 contains a list of the type of information that the ZUS or KRUS agency might request from DIO/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.
C. Exhibit of Form PL/USA3
The form PL/USA 3 may be printed from the SSA Totalization Forms section of the Totalization Resource Kit on the Division of International Operations (DIO) webpage.