Along with completing the SSA-2490-BK (Application for Benefits under a U.S. International Agreement), an applicant for Chilean benefits must complete a special Chilean application form. The form will vary depending on whether the applicant files for a life or survivor benefit.

The field offices (FO) do not take the special Chilean application forms. After the Social Security Administration receives a claim for Chilean benefits, the Chilean agency mails the appropriate Chilean application to the applicant. The Chilean agency will instruct the applicant to complete the forms (CHI/USA 1 - Pension Request-Worker or CHI/USA 2 - Pension Request-Survivor) and mail them back directly to the Chilean agency.

If an applicant submits a Chilean application to the FO:

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  provide assistance to complete the form;

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  photocopy and certify any documents (evidence) the Chilean agency requests the applicant to include with the Chilean claim; and

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  return the form(s) to the applicant and inform the applicant to mail it directly to the Chilean agency at the appropriate address shown on the application form.

REMINDER: Do not mail the Chilean forms to the Division of International Operations (DIO).

GN 00301.105 Certification of Evidence for Totalization Claims