Complete the items in Part 1 as follows:

• •

  Item a, Name of Worker

  Enter the first and last names of the worker.

• •

  Item b, Full Name at Birth

  Enter the full name at birth.

• •

  Item c, U.S. Social Security Number

  Enter the worker’s U.S. Social Security Number.

• •

  Item d, – Netherlands Insurance Number

  Enter the worker's Netherlands Insurance Number if shown on the application or on the Dutch Liaison form. (Sometimes different numbers are provided for Sociale Verzekeringsbank (SVB) and Uitvoeringsinstituut Werknemers Verzekeringen (UWV).)

• •

  Item e, Father’s Name

  Enter the worker’s father’s name.

• •

  Item f, Mother’s Maiden Name

  Enter the workers mother’s maiden name.

• •

  Item g, Name of Claimant

  Enter the name of the Claimant (include Maiden Name).

• •

  Item h, Address and Telephone Number of Claimant

  Enter the address of the Claimant and telephone number of claimant.

• •

  Item i,

  Select the type of claim.

• •

  Item j,

  Enter the date the claimant filed the application.

1. a. 

   Complete the items in Part 2, Item a as follows:

   • •

     Birth Date

     Enter the dates of birth for all claimants named in the preceding column. In DIO only, enter a checkmark if a date of birth has been used to award U.S. benefits or is showing on the MBR as proven.

   • •

     Name

     On initial claims packages, enter the first, middle, last and, if applicable, the maiden names of all claimants for Dutch benefits.

   • •

     Month Entitled - (DIO only)

     On initial claims packages or in response to a Dutch agency's request, enter, for each claimant named, the first month the beneficiary received a full monthly benefit payment or the effective date of the agreement, whichever is later.

     In survivor claims, enter the first month in which the beneficiary received a full survivor benefit, not an auxiliary life benefit. If DIO has not awarded benefits, enter “none.” If DIO suspended benefits since the initial date of entitlement, advise the Dutch agency that SSA is not paying benefits.

   • •

     Monthly Amount -

   Whenever DIO makes a Month Entitled entry, also enter the monthly amount prior to Supplemental Medical Insurance (SMI) deductions and taxes, i.e., the Monthly Benefit Credited (MBC). For beneficiaries who are dually entitled or entitled on another SSN, provide the total MBC, regardless of the SSN on which they are entitled.

2. b. 

   Complete the items in Part 2, Item b as follows:

   Date of Death

   On initial survivor claims, enter the worker's date of death and (in DIO only) if DIO has proof of the date of death, enter a checkmark.

3. c. 

   Complete the items in Part 2, Item c as follows:

   Date of Marriage

   On initial spouses' or widows' claims, enter the date of marriage and (in DIO only) if it has been proven, enter a checkmark.

4. d. 

   Complete the items in Part 2, Item c as follows:

   Date of Divorce

   On initial claims for divorced spouses, enter the date of divorce and (in DIO only) if DIO has proof of the date of divorce, enter a checkmark.

5. e. 

   Complete the items in Part 2, Item e as follows:

   Question 1

   • •

     On all initial claims packages for Dutch survivor benefits or in response to a Dutch request, check YES or NO to indicate whether the worker was insured under U.S. law for U.S. benefits at the time of death. (For information on eligibility for Dutch benefits under the agreement, see GN 01725.125A.2.)

   • •

     On all initial claims packages for Dutch disability benefits or in response to a Dutch request, check YES or NO to indicate whether the worker is insured for U.S. benefits at the onset of disability. (For information on eligibility for Dutch benefits under the agreement, see GN 01725.125A.2.)

   • •

     Refer to the information on how to determine whether a worker was insured at death or disability onset in GN 01726.325.

     Question 2

     On Dutch old-age claims, determine from the remarks section of the SSA-2490-BK (Application for Benefits Under U.S. International Social Security Agreement) whether the claimant has continuous residence in the U.S. or the Netherlands from age 59 and check YES or NO. (For information on eligibility for Dutch benefits under the agreement, see GN 01725.125A.1. Also see information on developing evidence in claims for Dutch benefits in GN 01725.210C.1.)

     Question 3

     On Dutch old-age claims, determine from the remarks section of the SSA-2490-BK whether the worker shares a household with another person and check YES or NO. (See GN 01725.210C.2.)

Check at least one block to indicate the type of material DIO is sending to the Dutch agency. Check item:

1. a. 

   Coverage Record, if attaching a U.S. coverage record.

2. b. 

   Medical Evidence, if attaching medical evidence submitted by the claimant or from SSA files.

3. c. 

   Information Requested, if responding to a request from a Dutch liaison agency, enter the date of the request.

4. d. 

   Other, if attaching material not covered by any block shown above, briefly explain the attachment in the “Remarks” section of Part 6.

Check at least one block to indicate the type of material DIO is requesting from the Dutch agency. Check item:

1. a. 

   Coverage Record, if requesting a Dutch coverage record.

2. b. 

   Medical Evidence, if requesting a copy of medical evidence from the Dutch agency's files.

3. c. 

   Status of Request Dated, show the date of the request if following up on an earlier request to the Dutch agency.

4. d. 

   Other, if DIO is requesting information not covered in a block shown above. Briefly explain your request.

Item a, Last Full Address in Netherlands

Determine the worker's last place of residence in the Netherlands from the remarks portion of the SSA-2490-BK and enter it in the space provided. (For information on the evidence required for U.S. Totalization benefits under the Dutch agreement, see GN 01725.205B.)

Item b, Name and Address of last Dutch employer

In Dutch disability claims, determine the name and address of the worker's last employer in the Netherlands from the remarks portion of the SSA-2490-BK and enter it in the space provided. (For information on developing evidence in claims for Dutch benefits, see GN 01725.210D.)

Keep remarks to a minimum and make them clear and concise. Do not use technical jargon or abbreviations.