GN 01726.235: Facts about the Dutch Liaison Form NL/VS 3

changes
←	*	→

~~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

POMS Reference

GN 01726.235: Facts about the Dutch Liaison Form NL/VS 3