The transmittal/request Form BE/USA 3 is the agreed upon form for a Belgian agency to:

• •

  transmit material to DIO or the FSP in Brussels,

• •

  send information to DIO or the FSP, and

• •

  request information from DIO.

The Form BE/USA 3 is printed in Flemish or in French. The Exhibit shown in the next section contains an English translation of all items on the form. Following is a description of the items on the Form BE/USA 3:

• •

  Part I contains general information about the claim.

• •

  Part II contains information about the worker and claimants.

• •

  Part III provides information about material that the Belgian agency is transmitting with the liaison form.

• •

  Part IV lists the information that the Belgian agency is requesting from SSA. This section includes a Privacy Act authorization to release information to Belgium.

• •

  Part V contains remarks.

The following forms are in English, Dutch, and French language. 

1. 1. 

   English

   To review this form select the attached PDF.

   View In PDF

2. 2. 

   Dutch

   To review this form select the attached PDF.

   View In PDF

3. 3. 

   French

   To review this form select the attached PDF.

   View In PDF