POMS Reference

This change was made on Jan 4, 2018. See latest version.
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GN 01749.220: Additional Application Form for Czech Benefits

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  • Effective Dates: 12/29/2017 - Present
  • Effective Dates: 01/03/2018 - Present
  • BASIC (03-09)
  • GN 01749.220 Additional Application Form for Czech Benefits
  • A. Introduction
  • Form CZ/USA 202, Claim for a Pension from the Czech Republic, is used to take claims for Czech benefits (solely or with U.S. Totalization) from persons filing the application in a field office (FO). This section explains how to download the application form and how to take a claim for Czech benefits using the Czech application form.
  • B. Claims Representative takes required application for Czech benefits
  • If an applicant files for Czech benefits:
  • * Access the Totalization Benefits Resource Kit on the intranet at http://ocoweb.ba.ssa.gov/oio/Totalization/TotResKit.asp
  • * Print the Czech application form (CZ/USA 202) and instructions. Give them to the applicant for completion.
  • * Provide assistance in completing the Czech form.
  • * Request an “Informational/Certified Earnings Record” (ICERS) per MSOM ICERS 001.004.
  • * Photocopy, stamp, and sign evidence submitted by the applicant.
  • * Send the completed Czech application form, certified copies of evidence, and certified earnings record (ICERS) to the Office of Earnings and International Operations (OEIO)/Division of International Operations (DIO) in Baltimore at the following address: Social Security AdministrationOEIO/DIO P.O. Box 17769 Baltimore, Maryland 21235-7769
  • * Send the completed Czech application form, certified copies of evidence, and certified earnings record (ICERS) to the Office of Earnings and International Operations (OEIO)/Division of International Operations (DIO) in Baltimore at the following address: Social Security Administration OEIO/DIO P.O. Box 17769 Baltimore, Maryland 21235-7769
  • NOTE: OEIO/DIO/ sends the claim to the Czech agency with the evidence and the worker’s U.S. coverage record.
  • NOTE: OEIO/DIO sends the claim to the Czech agency with the evidence and the worker’s U.S. coverage record.
  • * Complete the Modernized Development Worksheet (MDW) screen showing the date you sent the Czech claim to OEIO/DIO. Show “Totalization” as the ISSUE when completing the MDW screen.