Enter the first and last name(s) of the worker.

Enter the maiden name if the worker is a married woman; and

Enter the name at birth for a man, if it is different.

Check the appropriate sex of the worker.

Enter the Hungarian birth registration number/Hungarian Insurance number, if the number appears on the application or on the Hungarian liaison form. If the claimant did not provide the Hungarian birth registration number, indicate UNKNOWN in the Remarks field and provide the following information about the claimant:

• •

  given name,

• •

  surname,

• •

  date of birth, and

• •

  place of birth

Enter the worker’s U.S. SSN.

Enter claimant’s name.

If the claimant’s name has changed, enter the individual’s name at the time of birth.

Enter claimant’s U.S. SSN when he or she is not the worker entered in item A on the form.

Enter the complete address and telephone number of the claimant.

On initial claims packages, indicate the type of claim for U.S. benefits or Hungarian benefits in the appropriate columns.

Enter the filing date certified to the Hungarian liaison agency on all initial claims packages or in response to the agency’s request for the filing date.

Certification of Data

Complete the Certification of Data part of the form only when transmitting a claim for Hungarian benefits, in response to the Hungarian liaison agency’s request for specific information.

If the requested information is not available, indicate “unknown.” If our records do not verify the known requested information, enter the information but do not check the “Verified” block.

Enter the names of all claimants and, in survivor cases, the name of the deceased worker.

Enter the date of birth (DOB) for all claimants and, if applicable, for the deceased worker.

Check the “Verified” block if we used the DOB to award U.S. benefits, or if the master beneficiary record (MBR) has a proof code for the DOB.

Enter the deceased worker’s date of death in survivor claims.

Check the “Verified” block if SSA used the date of death to award U.S. benefits, or if the MBR has a proof code for the date of death.

Enter the date of marriage if a spouse or widow(er) is claiming benefits. Check “Verified” if we used the date of marriage to award U.S. benefits or if the MBR has a proof code for the date of marriage.

Enter the date of divorce if a divorced spouse or widow(er) is claiming benefits. Check “Verified” if we used the date of divorce to award U.S. benefits or if the MBR has a proof code for the date of the divorce.

Enter the country of birth for the worker. Check “Verified” if we used the data to award U.S. benefits or if the MBR has a proof code for the country of birth.

Enter the country of citizenship of the worker. Check “Verified” if we used the data to award U.S. benefits or if the MBR has a proof code for the worker’s citizenship.

Check this block when including a U.S. earnings record.

Check this block when including Hungarian applications.

Check this block when including medical evidence the claimant submitted or from SSA files.

Indicate the date of the Hungarian liaison agency’s request if responding to a request from them.

If attaching material not covered by any block shown, briefly explain the attachment in the space provided for “Remarks.”

Check this block to request the Hungarian certified coverage record.

Check this block to request medical evidence from the Hungarian liaison agency.

Check this block to follow up on an earlier request to the Hungarian liaison agency. Show the date of the original request in the space provided.

If requesting information not covered by items in GN 01756.220B.4.a. through GN 01756.220B.4.c., briefly explain the request in the space provided for in “Remarks.”