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1.
If there is a copy of the award form (SSA-101-U3) in the folder, see chart A.
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2.
If there is a copy of a Form SSA-2417-C1 (Determination of Benefit Rights) in the
folder, see chart B.
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3.
If there is only an MBR in the folder, see chart C.
Note: If BETs have any questions concerning the data which should be entered on the Forms
IT/USA 3, they should consult CAs, BAs or CATAs.
CHART A.—Based on form SSA-101-U3 (Determination of Award)
Monthly pension amount payable under United States legislation.
Pensione mensile da concedere in base alla legislazione statunitense.
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(b) |
(c) |
(d) |
(e) |
Full name of
beneficiary |
Relationship to worker |
Payable from |
Monthly amount based on U.S. periods of coverage only |
Monthly amount based on article 9.2 of the Agreement (Pro rata factor = 1) |
| Cognome e nome del beneficiario |
Relazione di
parentela con il
lavoratore
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Decorrenza |
Importo mensile erogabile sulla base dei soli periodi di assicurazione statunitensi |
Importo mensile erogabil in virtu dell articolo 9.2 dell'Accordo (Fattore pro rata
= 1)
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| Enter name(s) as shown in item 6 under “Name of Claimant.” |
Determine relationship to worker (see SM 00550.010) |
Enter date(s) from the later of either 11/78 or MOEN. |
Enter amount(s) which correspond to date(s) shown in item “6. BEN AMT.” of the SSA-101-U3. If the amount(s) differ from the MBA, enter the amount actually
paid or “000” if nothing was paid, in parentheses immediately following “BEN AMT.” Explain the reason for the difference; e.g., “partial payment work.”
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Complete this column if item 5 of the Form SSA-101-U3 shows PIA type “k” (totalization benefits awarded). |
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MBC can be found written in red on 3” ×5” attached to the Form SSA-101-U3 or on the
Form SSA-L3925.
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CHART B.—Based on form SSA-2417 (Determination of benefit rights)
Monthly pension amount payable under United States legislation.
Pensione mensile da concedere in base alla legislazione statunitense.
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| (a) |
(b) |
(c) |
(d) |
(e) |
Full name of
beneficiary |
Relationship to worker |
Payable from |
Monthly amount based on U.S. periods of coverage only |
Monthly amount based on article 9.2 of the Agreement (Pro rata factor = 1) |
| Cognome e nome del beneficiario |
Relazione di
parentela con il
lavoratore
|
Decorrenza |
Importo mensile erogabile sulla base dei soli periodi di assicurazione statunitensi |
Importo mensile erogabile in virtu dell articolo 9.2 dell'Accordo (Fattore pro rata
= 1)
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| Enter name(s) as shown in RID 4 under “NAME.” |
Determine relationship to worker. (See SM 00550.010.) |
Enter date(s) from the later of either 11/78 or MOEN. |
Monthly amounts are found in RID 4 under “BEN AMT.” Enter the amount(s) which correspond to the date(s) shown in column “(c)”. |
N/A |
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CHART C.—Based on MBR (SEE SM 00510)
Monthly pension amount payable under United States legislation.
Pensione mensile da concedere in base alla legislazione statunitense.
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| (a) |
(b) |
(c) |
(d) |
(e) |
Full name of
beneficiary |
Relationship to worker |
Payable from |
Monthly amount based on U.S. periods of coverage only |
Monthly amount based on article 9.2 of the Agreement (Pro rata factor = 1) |
| Cognome e nome del beneficiario |
Relazione di
parentela con il
lavoratore
|
Decorrenza |
Importo mensile erogabile sulla base dei soli periodi di assicurazione statunitensi |
Importo mensile erogabile in virtu dell articolo 9.2 dell'Accordo (Fattore pro rata
= 1)
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| See SM 00510.150 B. |
See SM 00510.150 A. and SM 00550.010. |
See SM 00510.150 E. |
See SM 00510.310 E. and SM 00510.310 G. |
N/A |
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Enter date(s) from the later of 11/78 or MOEN. |
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