POMS Reference

This change was made on Dec 29, 2017. See latest version.
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GN 01726.235: Facts about the Dutch Liaison Form NL/VS 3

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  • Effective Dates: 01/18/2017 - Present
  • Effective Dates: 12/29/2017 - Present
  • BASIC (08-94)
  • GN 01726.235 Facts about the Dutch Liaison Form NL/VS 3
  • A. Process
  • The Dutch agencies use liaison form NL/VS3 to:
  • * transmit material to DIO or the FSPs in London and Dublin
  • * send information to DIO or the FSPand
  • * request information from DIO
  • B. Exhibit of form NL/VS3 (English version)
  •  
  • NL/VS 3
  • NETHERLANDS/USA AGREEMENT ON SOCIAL SECURITY
  • To:
  • ( )
  • Social Security Administration Office of International Operations P.O. Box 17049 Baltimore, Maryland 21235 U.S.A.
  • Social Security Administration Division of International Operations P.O. Box 17769 Baltimore, Maryland 21235–7769 USA
  • From:
  •  
  • ( )
  • U.S. Embassy, FBU, 42 Elgin Rd, Ballsbridge, 4 Dublin, IRELAND
  •  
  • * INFORMATION ABOUT THE CLAIM
  • * Name of worker
  • *   
  •  
  •  
  •  
  •  
  • * Dutch Social Insurance Number
  • *  
  •  
  •  
  •  
  •  
  • * U.S. Social Security Number
  • *  
  •  
  •  
  •  
  •  
  • * Type of Claim
  •  
  • U.S.
  • Dutch
  •  
  • * old age
  • survivor
  • disability
  • * ( )
  • ( )
  • ( )
  • * ( )
  • ( )
  • ( )
  • * Date of Claim
  • *  
  •  
  • * day
  • month
  • year
  • * Name and Address of Claimant
  • *  
  • * VERIFICATION OF INFORMATION
  • * The Worker
  •  
  • day/month/year
  • verified
  • full name at birth             
  •  
  •  
  • date of birth
  •         
  •    ( )
  • date of death
  •        
  •    ( )
  • NL/VS 3
  • b.  Spouse or Widow(er)
  • day/month/year
  • verified
  • full name             
  •  
  •  
  •  
  •  
  •  
  • date of birth
  •  
  • ( )
  • date of marriage
  •  
  • ( )
  • date of divorce
  •  
  • ( )
  •  
  • c.  Children
  • date of birth day/month/year
  • verified
  • Name        
  •  
  • ( )
  • Name        
  •  
  • ( )
  • * MATERIAL ATTACHED
  • *  ( ) No Material
  • *  ( ) Dutch Insurance Record (NL/VS 205)
  • *  ( ) Medical Evidence
  • *  ( ) Information Requested on                     
  • day/month/year                                
  • *  ( ) Other (see remarks)
  • * INFORMATION REQUESTED FROM U.S.A. This information is needed to process a claim under the agreement.   ( )Yes    ( )No
  • *  ( ) No Information Needed
  • *  ( ) Entitlement moneth and benefit amount for:      
  • *  ( ) US Insurance Record
  • *  ( ) Medical Evidence
  • *  ( ) Status of Request Dated           day/month/year
  • * REMARKS
  •  
  • STAMP      
  •  
  •  
  • Signature of SVB/SWV Employee
  • Date
  • C. Description of form NL/VS3
  • * Part 1 (INFORMATION ABOUT THE CLAIMS) contains general information about the claim including, if known, the U.S. SSN
  • * Part 2 (VERIFICATION OF INFORMATION) contains spaces for the Dutch agencies to indicate the claimants' names, dates of birth and other event dates and to indicate whether these dates have been verified by acceptable evidence.
  • * Part 3 (MATERIAL ATTACHED) contains information from the Dutch agency that indicates whether evidence is attached.
  • * Part 4 (INFORMATION REQUESTED FROM USA) contains a list of the types of information that a Dutch agency might request from DIO. A check in block b., “an agreement claim has been made” constitutes authority to disclose information to the Dutch in the absence of a signed U.S. application form SSA-2490, Dutch application form NL/VS 202 or 203 or other signed statement.
  • * In the REMARKS portion the Dutch agencies often ask for a form “VS/ NL 205” . Such a form does not exist, however, in these instances the Dutch agencies are really requesting a U.S. earnings record.
  • * A Dutch agency's request for a “copy of the decision” means that they want to know the claimant's month of entitlement to U.S. benefits and the monthly benefit amount. See GN 01726.220.D.4