TN 3 (03-97)
The transmittal/request form D/USA 3 is used by the German agencies to:
transmit material to DIO or the FSP,
send information to DIO or the FSP, and
request information from DIO
Front
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Back
Part I contains general information to identify the proper worker, address, U.S. SSN and German Insurance Nuumber. The “from” block indicates which German agency sent the form.
Part II (Transmittal of Information by German agency) is used by the German agency to indicate which information or evidence is attached or will follow. Item G of Part II is used to notify DIO that the agency indicated has jurisdiction of the claim in Germany.
Part III (Request for Information from U.S. - SSA) contains a list of the types of information that a German agency might request from DIO. A check mark in the first block of Part III, indicating that there is a claim under the agreement, constitutes authority to disclose information to the German agency in the absence of a signed SSA-2490 or other signed authorization statement.
A checkmark in the second block of Part III indicates that the German agency needs the information for a reason other than a claim under the agreement, such as the verification of an insurance record or the splitting of pension entitlement. When this block is checked, information cannot be disclosed unless a signed consent form (D/USA 7) from the worker or claimant is attached or a signed application form SSA-2490-F4 is in file.
In addition to the procedures for handling foreign agency liaison forms contained in GN 01704.000, the following applies:
In DIO determine if a U.S. claim's lead exists by following the instructions in GN 01703.063. If a form D/USA 4 is attached, refer to GN 01708.240C.
If a U.S. claim lead exists, respond to the German assistance request (if any) via form SSA-2960-U3-GE and then forward the case to the CA.
If there is no U.S. claims lead and the response consists only of a single attachment, respond to the German request either by SSA-2960-U3-GE or by attaching the response to the D/USA 3 and reversing the addresses on the form.
In the FSP, assume that there is a U.S. claims lead and follow GN 01708.015.
German agency requests for medical evidence or examinations will be made in Part III.C. Refer to GN 01708.310 and GN 01708.315 to process those requests.
Obtain a current MBR to respond to German agency requests for address information (Part III.E.). If the MBR is “NIF,” inform the German agency that address information is not available in our records for the claimant.
Follow GN 01708.245 to process German agency requests for certification of the payment of U.S. Child's insurance benefits (Block III.J.)
Follow GN 01708.320 to process German agency requests for monthly benefit information in blocks III.G. and III.H. If the claimant is age 65 or over, assume that the German agency is also requesting Medicare Part B information and see GN 01708.220D.7.