GN 01722: DIO and FSP Processing Under the Agreement with Spain
BASIC (01-94)
A. Exhibit — Spanish version
| MINISTERIO DE TRABAJO Y SEGURIDAD SOCIAL | |
| Secretaria General para la Seguridad Social | |
| Instituto Nacional de Seguridad Social | |
| Social Security Administration Division of International Operations P.O. Box 17769 Baltimore, MD 21235–7769 Estados Unidos de America |
SU REFERENCIA: ..............................
PRESTACION: .................................
SOLICITANTE: ................................
CAUSANTE: ...................................
FECHA NACIMIENTO: DD/MM/AA
No. DE AFILIACION EN ESPANA: / / .
No. DE AFILIACION EN USA: / / .
Acusamos recibo de la documentacion de referencia, informandose que con esta misma fecha se remite a:
-
DIRECCION PROVINCIAL DEL INSTITUTO
NACIONAL DE LA SEGURIDAD SOCIAL
DOMICILIO
PROVINCIA
competente para el tramite y resolucion del correspondiente expediente y a la que deberan dirigirse en lo sucesivo para todo lo relacionado con dicha peticion.
EL SUBDIRECTOR GENERAL DE GESTION
P.D. LA JEFE DEL SERVICION DE COLABORACION
AMINISTRATIVA Y PRESTACIONES A CORTO PLAZO
B. Exhibit — English version
| Department of Labor and | |
| Social Security | |
| Central Social Security Office | |
| Social Security Administration Division of International Operations P.O. Box 17769 Baltimore, MD 21235–7769 United States of America |
YOUR REFERENCE: ...............................
TYPE OF CLAIM: ................................
APPLICANT: ....................................
WAGE EARNER: ..................................
DATE OF BIRTH: DAY/MONTH/YEAR
SPANISH SOCIAL SECURITY NUMBER: / / .
U.S. SOCIAL SECURITY NUMBER: / / .
We acknowledge receipt of the documentation in reference and we inform you that on this same date it is being forwarded to:
-
PROVINCIAL OFFICE OF THE NATIONAL
INSTITUTE OF SOCIAL SECURITY
ADDRESS
PROVINCE
competent for the development and adjudication of the corresponding claim and to which all future inquiries regarding said claim must be addressed.
THE DEPUTY GENERAL DIRECTOR FOR OPERATIONS
P.D. THE CHIEF OF THE DEPARTMENT OF ADMINISTRATIVE COLLABORATION AND SHORT-TERM BENEFITS