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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.
The materials available at this web site are provided free of charge, for informational purposes only, and without warrant by True Link Financial, Inc., and are not legal advice or Social Security benefits advice. You should contact your attorney to obtain advice with respect to any particular issue or problem, or the Social Security Administration with any general inquiries. Click here to view this section of the POMS on the Social Security Administration website.