Complete Part A in all claims for QPP benefits. Include general information about the worker (contributor).

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  Item 1 - Check either French or English even if the applicant has no preference. If the last Canadian province in which the worker lived was Quebec, the QPP has jurisdiction; otherwise, the Canada Pension Plan (CPP) has jurisdiction and the applicant should complete the CDN-USA 1 rather than the QUE/USA-1.

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  Item 7 - If separated, enter the date the worker and the spouse began living apart, regardless of whether legally separated at the time.

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  Item 10 - Include natural, adopted or stepchildren of the worker, regardless of age or marital status of the children.

Complete Part B if the applicant is applying for a retirement benefit.

Complete Part C if the applicant is applying for a disability benefit.

Complete Parts D and E if the applicant is applying for survivor's benefits.

Complete Part F in all claims for QPP benefits. The applicant must sign and date the application.

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  Where the applicant signs by mark, the signature must be witnessed.

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  If the application is signed in the presence of an SSA employee, the SSA employee may sign as witness and enter the field office (FO) address.

This section is completed only by staff in the Office of International Operations (OIO) or one of the designated border offices (at the Claims Representative level or higher) identified in GN 01715.320. It informs the Quebec agency which, if any, of the eligibility factors shown have been verified for SSA purposes.

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  Always enter the date claim filed in the first block. This date will be the date of filing in the FO or an earlier protective filing date, if applicable.

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  Make entries in the remaining blocks only if the relevant date has been established for SSA purposes either in connection with a

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    concurrent retirement, survivors or disability claim, or

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    prior claim and the date is available from the master beneficiary record (MBR).

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  For each date established by SSA, enter the date in the appropriate space and check the “Verified” box. (The date that has been proven for SSA purposes is entered even if different than the alleged date.)

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  If SSA has not established a particular date, make no entry.

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  When surviving spouse's benefits are claimed, enter the surviving spouse's name and date of birth (if established for SSA purposes) in the appropriate space and check the “Verified” box.

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  Enter any children's names and dates of birth (if established for SSA purposes) in the appropriate spaces and check the “Verified” box.

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  Enter the name and address of the office in the space designated “Name of the Institution” (e.g., SSA field office, Burlington, Vermont).

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  Sign and date in the space provided and also print the name and title of the individual completing this section.

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  Stamp the section in the space provided with the date stamp used to date stamp applications for U.S. benefits.