The following chart lists the application forms that must be completed when the applicant
is filing in a U.S. Field Office (FO). Foreign Service Posts should follow the instructions
in the subchapters dealing with the specific Agreements when determining which application
form to take.
All application forms listed in the chart are available through the Totalization Benefits
Resource Kit on the Intranet here.
Applicant is Filing For
|
Agreement With
|
U.S. Totalization Benefit Only
|
U.S. Totalization & Foreign Benefit
|
Foreign Benefit Only
|
|
1. Australia
|
SSA-2490-BK (Part I only) and appropriate RSDI application(s)
|
SSA-2490-BK (Part I only), AUS/USA 4 and Form Mod (i) (see GN 01743.215) and appropriate RSDI application(s)
|
AUS/USA 4 and Form Mod (i) (see GN 01743.215)
|
|
2. Canada
|
SSA-2490-BK (Part I only) and appropriate RSDI application(s)
|
SSA-2490-BK (Part I only), CDN/USA 1 and/or QUE/USA1 (see GN 01715.220 or GN 01715.230) and appropriate RSDI application(s)
|
CDN/USA 1 and/or QUE/USA 1 (see GN 01715.220 or GN 01715.230)
|
|
3. Czech Republic
|
SSA-2490-BK (Part I only) and appropriate RSDI application(s)
|
SSA-2490-BK (Part I only), CZ/USA 202 (see GN 01749.220) and appropriate RSDI application(s)
|
CZ/USA 202 (see GN 01749.220)
|
|
4. South Korea
|
SSA-2490-BK (Part I only) and appropriate RSDI application(s)
|
SSA-2490-BK (Part I only), KOR/USA 1 (see GN 01741.215) and appropriate RSDI application(s)
|
KOR/USA 1 (see GN 01741.215)
|
|
5. Japan
|
J/USA 4 (see GN 01745.215) and appropriate RSDI application(s)
|
J/USA 4 (see GN 01745.215) and the appropriate Japanese application form (see GN 01745.220) and appropriate RSDI application(s)
|
Appropriate Japanese application form (see GN 01745.220)
|
|
6. Spain
|
SSA-2490-BK (Part I only) and appropriate RSDI application(s)
|
SSA-2490-BK (Part I only), E/USA (see GN 01721.220) and appropriate RSDI application(s)
|
E/USA (see GN 01721.220)
|
|
7. All Other
Countries
|
SSA-2490-BK (Part I only) and appropriate RSDI application(s)
|
SSA-2490-BK (Parts I and II) and appropriate RSDI application(s)*
|
SSA-2490-BK (Parts I and II)*
|
* Some countries require that an applicant also complete an additional special application
for foreign benefits. When such an application is required, it is mailed directly
to the applicant by the Office of International Operations (OIO) or the foreign agency.