Most entries on the form are self explanatory with the exception of those specifically
listed below:
Evidence of Coverage Periods
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Ottawa checks this block when they are providing a record of Canadian coverage for
someone who has filed for U.S. benefits.
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When a person has no coverage in Canada, Ottawa enters a zero in the total block.
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When coverage appears in this section for a year after the year of alleged disability
onset, Ottawa will provide information if the coverage is based on work.
Certification of Data
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Ottawa uses this section to certify the date claim filed and vital statistics data
pertaining to the worker and his family taken from their records.
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These dates will be used without further verification unless there is a material discrepancy
with other evidence in file (See GN 01701.210).
Information Required From United States
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Ottawa has provided a statement at the beginning of the section which eliminates the
need for a copy of the individual's consent before we can release the requested information.
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Ottawa will provide a consent form require information about an individual who has
not filed a claim under the agreement.
Medical Evidence
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Ottawa checks the block to request a copy of medical evidence in DIO files.
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If there is no medical evidence in file, the remarks portion of the SSA-e2960-U3-CQ
will show, “No Medical Evidence in File.”
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Do not request a medical examination.