Complete the Certification of Data part of the form only when transmitting a claim
for Czech benefits in response to CSSZ for specific information.
If the requested information is not available, indicate “unknown.” If the requested
information is available, but not verified in SSA records, enter the information but
do not check the “Verified” block.
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Enter the names of all claimants and in survivor cases, the name of the deceased worker.
Enter the first and last names and, if applicable, the maiden name.
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Enter the date of birth for all claimants and, if applicable, for the deceased worker.
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Enter the place of birth for all claimants and, if applicable, for the deceased worker.
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Enter the relationship for all claimants.
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Enter the date the information is provided.
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Check the “Verified” block if SSA used the date of birth to pay U.S. benefits, or
the MBR has a proof code for the date of birth.
b. Worker/contributor’s date of death
Enter the deceased worker’s date of death in survivor claims. Check the “Verified”
block if SSA used the date of death to pay U.S. benefits, or the MBR has a proof code
for the date of death.
Enter the marriage if a spouse or widow(er) is claiming benefits. Check “Verified”
if SSA used the date of marriage to pay U.S. benefits or 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 SSA used the date of divorce to pay U.S. benefits or the MBR has
a proof code for the date of the divorce.
Enter the country of citizenship for the worker. Check “Verified” if SSA used the
data to pay U.S. benefits or the MBR has a proof code for the worker’s citizenship.
f. Certification of orphan child in school age 16-26
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Enter the name(s) of the orphan child in school age 16-26.
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Enter the name of the school for the orphan child school age 16-26.
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Enter the presumed date of graduation for the orphan child school age 16-26.
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Check the “Verified” block if SSA used the data to pay U.S. benefits, or the MBR has
a proof code for the data.