• •

  Refer to GN 01720.025 to determine the proper agency

• •

  If the proper agency is other than the agency in Newcastle upon Tyne, affix the applicable pre-printed label of the proper agency provided to the totalization modules over the pre-printed address of the agency in Newcastle upon Tyne orblock print the proper agency and address.

• •

  Check the appropriate box in the "From" block.

Always complete items A-C.

• •

  Item A - Enter the first name(s), middle and last name of the worker. If applicable, show the worker's maiden name after the last name.

• •

  Item B - Enter the worker's U.S. Social Security number.

• •

  Item C - Enter the worker's U.K. National Insurance Number as shown on the application form or on the U.K. liaison form.

  NOTE: The number consists of a two-letter alpha prefix, followed by a six-digit serial number and ending with a single alpha suffix, e.g. TK 987654 A.

Complete items D and E if you are transmitting a claim or protective filing date to the U.K. agency.

• •

  Item D - Enter the type of U.K. benefits that are being claimed.

• •

  Item E - Enter the filing date to be certified to the U.K. agency.

Always complete item F unless you are responding to an assistance request from a U.K. agency.

• •

  Item F - Enter the claimant's name only if the claimant is not the worker. Always enter the claimant's address.

• •

  Name -Always enter the names of all claimants.

  Enter the first name, middle and last names and if applicable, the maiden name.

• •

  Date of birth - Enter the date of birth for all claimants listed.

• •

  Verified - (Completed only by OIO) Check this block if:

  The date of birth has been used to award U.S. benefits,OR
  the date of birth is shown on the MBR as proven.

• •

  Dates of death, marriage and divorce - Complete these items, as appropriate, only if transmitting a claim for U.K. benefits, OR responding to a U.S. agency's request for this information.

• •

  "Verified" (Completed only by OIO) - Check this block if the data has been used to award U.S. benefits, ORthe data is shown on the MBR as proven.

Check at least one block to indicate the type of material being sent to the U.K. agency. Check item:

1. A. 

   if attaching a U.S. coverage record.

2. B. 

   if attaching medical evidence submitted by the claimant or from SSA files.

3. C. 

   if responding to a request from a U.K. liaison agency and enter the date of the request.

4. D. 

   if no material is attached.

5. E. 

   if attaching material not covered by any block shown above and briefly explain the attachment.

Check at least one block to indicate the type of material being requested from the U.K. agency. Check item:

1. A. 

   if requesting a U.K. coverage record.

2. B. 

   if requesting a copy of medical evidence from the U.K. agency's files.

3. C. 

   if following up on an earlier request to the U.K. agency and show the date of the request.

4. D. 

   if you are not requesting any information.

5. E. 

   if you are requesting information not covered by a block shown above. Briefly explain your request in Part V.

• •

  Keep remarks to a minimum and make them clear and concise. Do not use technical jargon or abbreviations.

• •

  Be sure to sign and date the form. On follow-up requests, enter the follow-up date on the yellow follow up copy and on the blue file copy.