The only acceptable form for the certification of Dutch coverage is the NL/ VS 205. Route certifications in any other format to CPS. The form is usually sent under cover of liaison Form, NL/VS 3.

The following is a description of Form NL/VS 205.

• •

  The upper part of the NL/VS 205 contains a space for entering the U.S. SSN, if known.

• •

  Part 1 contains all necessary identifying information about the insured person and is self-explanatory.

• •

  Part 2 contains periods of creditable Dutch coverage in the European style, i.e. day, month, year.

• •

  “From-to” periods will often span many years.

• •

  The number of months of coverage in a period are not reflected. However, all periods of Dutch coverage are continuous periods, i.e. all months within a given “from-to” period are coverage months.

• •

  If there is a break in coverage, a new period identified by a new beginning date is shown.

• •

  Records certified by SVB contain coverage information beginning with January, 1957 or the first month of coverage, if later.

• •

  Records certified by UWV contain coverage information beginning with July, 1967 or the first month of coverage, if later.

• •

  A provisional record can be recognized by the word “provisional” written somewhere on the form or by the appearance of coverage periods which are later than the date the form was completed. (See GN 01726.115 for a discussion of provisional records.)

• •

  The agency which issued the record is indicated at the bottom of the form, in the event that additional information or explanation are required.

NL/VS205

VERDRAG INZAKE SOCIALE ZEKERHEID TUSSEN HET KONINKRIJK DER NEDERLANDEN EN DE VERENIGDE STATEN VAN AMERIKA AGREEMENT ON SIOCIAL SECURITY BETWEEN THE KINGDOM OF THE NETHERLANDS AND THE UNITED STATES OF AMERICA

Aan/To Social Security Adminstration U.S.A.

U.S. Social Security Number                                          

Verklaring over Nederlandse verzekeringstijdvakken betreffende:

Certification of Netherlands creditable periods concerning:

•  

  - invalidity insurance

  - General Old-Age insurance

  - General Widow's and Orphan's insurance

  - Childrens' allowances

1. 1. 

   VERZEKERDE/INSURED PERSON

   1.1

   Naam
   Family Name                                      

   1.2

   Voorna(a)m(en)
   Given name(s)                                     

   1.3

   Geboortenaam
   Maiden Nama                                      

   1.4

   Geboortendatum                                    
   Date of birth      dag/day     maand/month    jaar/year

   1.5

   Geboorteplaats
   Place of birth                                      

   1.6

   Registratienummer  UWV
   Netherlands employee security number
   SVB Dossiernummer                               
   Netherlands social security number

1. 2. 

   VERZEKERINGSTIJDVAKKEN/CREDITABLE PERIODS

   In Nederland/In the Netherlands

( )Social Insurance Bank  ( )Gemeenschappelijk Administratienkant  ( )Bedrijfsvereniging

(handtekening/signature)   (datum/date)    stempel/stamp