TN 1 (03-99)

A. Policy

An applicant filing for benefits under the agreement with the Netherlands must complete Form SSA-2490-BK (Application for Benefits Under A U.S. International Social Security Agreement). This is true whether the applicant is filing for benefits only from the United States, only from the Netherlands or from both countries.

B. Process

The SSA-2490-BK is available through MCS, but the MCS version may only be used when the NH is filing for

• U.S. retirement or disability Totalization benefits alone, or

• U.S. retirement or disability benefits (regular or Totalization) and concurrently for Dutch benefits.

The MCS version of the SSA-2490 may not be used to file for

• Dutch benefits only, or

• U.S. or Dutch survivors benefits.

A paper SSA-2490-BK application form must be used in the latter cases.

NOTE: It is not necessary to take an SSA-2490-BK in claims for U.S. auxiliary benefits in life cases or in survivor cases where there was a previously approved award in a life case since this application would have been completed previously in connection with the NH's claim.

C. Procedure - required applications

Use the following information to determine which applications must be completed when taking claims for U.S. Totalization benefits and/or Dutch benefits under the agreement with the Netherlands.

1. U.S. Totalization benefits only

a. Retirement or disability claims

In retirement or disability claims, complete the appropriate retirement or disability benefit MCS application screens, the TOTALIZATION (TOTL) screen (see MSOM MCS 009.011), and the SSA-2490 screens (see MSOM MCS 007.001).

b. Survivors claims

In survivors claims, complete the appropriate MCS application screens, the TOTALIZATION (TOTL) screen (see MSOM MCS 009.011), and Part I of the paper application Form SSA-2490-BK.

2. Dutch benefits only (rRegular or totalization)

Claims for Dutch benefits only (Regular or Totalization) are MCS exclusions. Complete Parts I and II of the paper application Form SSA-2490-BK .

3. Dutch benefits (regular or totalization) and U.S. (regular or totalization) benefits

a. Retirement or disability claims

In retirement or disability claims, complete the appropriate retirement or disability benefit MCS application screens, the TOTALIZATION (TOTL) screen (see MSOM MCS 009.011), and the SSA-2490 screens (see MSOM MCS 007.001).

b. Survivors claims

In survivors claims, complete the appropriate MCS application screens, the TOTALIZATION (TOTL) screen (see MSOM MCS 009.011), and Parts I and II of the paper application Form
SSA-2490-BK.

D. References

• Completing the SSA-2490 screens on MCS, MSOM MCS 007.001

• Application for Benefits Under a U.S. International Social Security (Totalization) Agreement (Form SSA-2490-BK), GN 01702.110