TN 1 (09-84)

A. Opening Paragraphs

17000A REFERENCE TO TOTALIZATION APPLICATION

We are writing to give you information about your claim for benefits under the agreement between the United States and (1).

1. Name of country

17000B

We are writing to give you information about (1) claim for benefits under the Social Security agreement between the United States and (2) on the record of (3).

1. Claimant’s name possessive

2. Name of country

3. Numberholder’s name

17001 REFERENCE TO TOTALIZATION INQUIRY — GENERAL

Thank you for your letter of   (a)   .

(a)

Show Date

17002 REFERENCE TO TOTALIZATION INQUIRY — SPECIFIC COUNTRY

Thank you for your letter concerning the international Social Security agreement between the U.S. and   (a)   .

(a)

Name of Country

17003 INQUIRY REFERRED FOR REPLY

Your letter of   (a)   has been referred to this office for reply.

(a)

Show Date

17004 THIRD PARTY INQUIRY

We have received a letter on your behalf from   (a)   concerning   (b)   .

(a)

Name of Third Party

(b)

Subject of the Inquiry

17005 DELAY IN RESPONDING TO INQUIRY

We regret the delay in responding to your inquiry.

B. General Information About Totalization

17010 GENERAL EXPLANATION OF INTERNATIONAL SOCIAL SECURITY AGREEMENTS

The 1977 amendments to the Social Security Act authorize the President to enter into international Social Security agreements. Each agreement provides for coordinating parts of the Social Security programs of the U.S. and the foreign country. Agreements generally eliminate dual coverage situations in which a worker must pay Social Security taxes to both countries for the same work. Agreements also provide for combining the coverage and earnings of an individual who has worked in both countries to determine eligibility for and entitlement to benefits.

17011 EFFECTIVE DATE OF AGREEMENTS — GENERAL

An international Social Security agreement cannot become effective until it is approved by the U.S. Congress. An agreement will be considered approved unless either House of Congress takes action to disapprove it within 60 session days after submittal. Once an agreement is approved, each country must formally notify the other that it has complied with all legal requirements for its entry into force. Each agreement provides for a specified effective date after such formal notification.

17012 EFFECTIVE DATE OF NEGOTIATED, UNAPPROVED AGREEMENT — GENERAL

Although the U.S. and   (a)   have concluded an international Social Security agreement, it must still be approved by Congress and accepted by both countries. It is not expected to become effective before   (b)   .

(a)

Name of Country

(b)

Date — Use general term such as “Mid or Late 1982.”

17013 EFFECTIVE DATE OF AGREEMENT IN FORCE

An international Social Security agreement with   (a)   became effective on   (b)   .

(a)

Name of Country

(b)

Effective Date of Agreement

17014 SPECIFIC INQUIRY AND/OR INTEREST IN FILING — AGREEMENT NOT EFFECTIVE

Until this agreement becomes effective and the requirements are established, we are unable to answer specific questions or consider any request as an application.

17015 KEEPING INFORMED FOR EFFECTIVE DATE OF NEGOTIATED, UNAPPROVED AGREEMENT

You should continue to watch for public announcements concerning the effective date of this agreement or contact your nearest   (a)   periodically.

(a)

Social Security office and/or foreign agency (specify); U.S. diplomatic or consular office and/or foreign agency (specify name of agency).

17016 AGREEMENT NOT YET NEGOTIATED

The U.S. does not have an international Social Security agreement with   (a)   . If an agreement is negotiated in the future, an application may be filed on or after the effective date.

(a)

Name of Country

17017 DUAL COVERAGE — AGREEMENT NOT YET NEGOTIATED/EFFECTIVE

Work that is covered by the Social Security systems of the U.S. and    (a)   is still subject to Social Security taxes in both countries.

(a)

Name of Country

17018 FILING AN APPLICATION — AGREEMENT NOT YET EFFECTIVE

An application for benefits under the agreement may be filed with the U.S. Social Security Administration or the social insurance system in   (a)   when the agreement becomes effective.

(a)

Name of Country

17019 REFERRAL TO OTHER COUNTRY

We suggest you contact the Social Security system in   (a)   regarding the possibility of receiving benefits from that country.

(a)

Name of Country

17020 REFERRAL OF INQUIRY TO OTHER COUNTRY

We have received your inquiry about   (a)   . However, we are unable to answer your question(s). Your letter has been forwarded to the proper agency in   (b)   for reply.

(a)

Subject of Inquiry

(b)

Name of Country

17021 REFERRAL TO PAMPHLET

We have enclosed a booklet that describes how work credits from both countries can be counted to qualify for benefits.

Enclosure:

17022 CLAIMANT QUESTIONS A FOREIGN COUNTRY'S DECISION

An international Social Security agreement does not change a country's requirements for entitlement to benefits. Each country must determine a claimant's entitlement separately based on its own laws. Therefore, a person could become entitled to benefits from one country but not the other even though the countries have an agreement. Since the requirements for entitlement and the conditions for payment of benefits vary greatly from country to country, we are unable to answer your inquiry. We have forwarded your letter to the proper agency in   (a)   for reply.

(a)

Name of Country

C. Coverage and Benefits

17030 COMBINING COVERAGE UNDER MORE THAN ONE AGREEMENT

When an individual has work covered by the Social Security systems of two or more countries which have agreements with the U.S., the coverage from only one of those countries can be combined with U.S. coverage to determine eligibility for and entitlement to benefits payable by the U.S. The coverage from the foreign Social Security system that yields the highest benefit when combined with U.S. coverage will be used unless the persons receiving benefits on that record choose the coverage which yields a lower benefit.

17031 COVERAGE REQUIRED FOR U.S. TOTALIZATION BENEFITS

To be eligible for U.S. benefits under an international agreement, a worker first must have earned at least 6 quarters of coverage under the U.S. Social Security system. Then, after combining coverage earned in both the U.S. and   (a)   , the worker must have enough quarters of coverage for entitlement to benefits. The coverage required for retirement, survivors and disability insurance benefits is explained in the enclosed booklet.

Enclosure: HEW Pub. No. (SSA) 05-10072

(a)

Name of Country

17032 HOW THE U.S. COMBINES COVERAGE UNDER THE INTERNATIONAL AGREEMENTS

Under the Social Security agreement with   (a)   , periods of coverage earned in   (b)   will be added to periods of coverage earned in the U.S. to determine whether or not an individual has worked long enough under Social Security to be eligible for U.S. benefits.

Generally, a quarter of coverage will be credited for every   (c)   of coverage earned in   (d)   with the following exceptions:

1. No quarter of coverage will be credited for any quarter in which a U.S. quarter of coverage is already credited.

2. No quarter of coverage will be credited for any period of coverage before 1937.

3. No quarter of coverage will be credited for any   (e)   .

Fill-ins:

(a)

Name of Country

(b)

Name of Country

(c)

13 weeks (Italy), 3 months (Germany and Switzerland)

(d)

Name of Country

(e)

Period of Voluntary coverage earned in Italy; excused period of coverage (AUSFALLZEIT) earned in Germany; Swiss period of coverage for which no work was performed and no contributions were made.

17033 HOW TOTALIZATION BENEFITS ARE COMPUTED

Benefits payable by the U.S. under an international Social Security agreement are computed by combining work covered under the Social Security systems of both countries. The resulting benefit amount is then reduced by the percentage of creditable quarters of work earned in the foreign country. Thus, the amount that is payable by the U.S. is a percentage of the benefit amount that would have been payable had all of the coverage been earned in the U.S. For example, if a worker earned 2/3 of his total creditable coverage in the U.S. and 1/3 in a foreign country, the benefit computed (after combining the earnings) would be reduced by 1/3. The monthly benefit payable by the U.S. would equal 2/3 of the amount payable had all coverage been earned in the U.S. (Please refer to the enclosed pamphlet for a more detailed explanation of how these benefits are figured.)

Enclosure: Pamphlet

Pamphlets

Italy - HEW Pub. No. (SSA) 05-10171

Germany - SSA Pub. No. 05-10715

Switzerland - SSA Pub. No. 05-10190

17034 HOW TOTALIZATION BENEFITS ARE PAID

Each country pays benefits under an international Social Security agreement separately. There is no exchange of funds between the two countries. If   (a)   entitled to benefits from both countries, checks will be issued by both countries.

(a)

A person is, you are

17035 TOTALIZATION BENEFITS AWARDED

We have received the information requested from the   (a)   agency concerning your earnings under its social insurance system. We have combined these earnings with your U.S. earnings and have determined that you are eligible for a U.S. totalization benefit of   (b)   effective   (c)   .

(a)

country

(b)

amount

(c)

date

D. Claims Leads and Filing Applications

17040 FILING AN APPLICATION — GENERAL

Please review the enclosed material. If you believe you may be eligible for benefits under the agreement, you should contact your nearest   (a)   to file an application.

Enclosure: Pamphlet (see list in 17033)

(a)

U.S. Social Security office, U.S. diplomatic or consular office

17041 FILING AN APPLICATION WHEN INQUIRER LIVES IN AGREEMENT COUNTRY

Since you reside in   (a)   , you may also file an application at   (b)   .

(a)

Country of agreement

(b)

any office of Istituto Nazionale di Previdenza Sociale (INPS) (Italy); any branch office of a German social insurance agency (Germany); the compensation fund of the canton in which you reside or one of its local branch offices (Switzerland)

17042 FURTHER DEVELOPMENT NEEDED ON TOTALIZATION CLAIM

You will be contacted shortly by   (a)   for additional information needed to process your claim for benefits from   (b)   .

(a)

the U.S. Social Security office in           , the German agency, etc.

(b)

Country of agreement

17043 RSDI AWARDED — TOTALIZATION CLAIM PENDING

We have received your   (a)   benefits under the Social Security agreement with   (b)   .   (c)   will contact you about this as soon as possible.

(a)

application for, inquiry about

(b)

Name of Country

(c)

We, the (name of DO) Social Security office, etc.

17044 POSSIBLE CLAIMS LEAD FOR SPOUSE — LIFE CLAIM

If your spouse has earned social security work credits in (1), he or she may be eligible for (2) benefits based on this work. Your spouse's eligibility may be based on work in (3) or a combination of work in (4) and the United States.

1. Name of totalization country

2. Adjective form of country

3. (Same as 1)

4. (Same as 1)

17045 POSSIBLE CLAIMS LEAD FOR SPOUSE — SURVIVOR CLAIM

If your deceased   (a)   earned Social Security credits in   (b)   or the U.S. (or both), you should apply for survivor's benefits on that person's work record. The enclosed pamphlet explains each country's requirements for benefits and tells how credits from both countries can be combined, if necessary, to help a person get benefits.

(a)

mother/father/husband/wife

(b)

Country of agreement

Enclosure: Pamphlet

Pamphlets

(Italy) HEW Publ. No. (SSA) 05-10171

(Germany) SSA Pub. No. 05-10715

(Switzerland) SSA Pub. No. 05-10190

17046 CLAIMS LEAD — CLAIM FILED WITH FOREIGN COUNTRY

We understand that you have applied for benefits from   (a)   which has an agreement on Social Security with the U.S. The enclosed pamphlet tells how work credits from both countries may be combined, if necessary, to help you qualify for U.S. Social Security benefits if you do not meet the normal U.S. work requirement. If you believe you qualify, contact the nearest   (b)   .

(a)

Country

(b)

Social Security office, U.S. diplomatic or consular office

Enclosure: Pamphlet

Pamphlets

(Italy) HEW Pub. No. (SSA) 05-10171

(Germany) SSA Pub. No. 05-10715

(Switzerland) SSA Pub. No. 05-10190

17047 REQUEST FOR CONSENT

A social insurance agency in   (a)   has requested information needed to process the claim for benefits that you filed with them. Under the provisions of the U.S./   (b)   international agreement on Social Security, we have agreed to assist them.

They have requested   (c)   .

Before we release this information or take further action on their request, we must have your consent. Please complete, sign and return the enclosed form(s). A preaddressed return envelope is enclosed for your convenience.

Enclosures: Consent Form, Return Envelope

(a)

Country

(b)

Country

(c)

Information requested

Pending Totalization Application

17048 PENDING TOTALIZATION APPLICATION

The (1) agency requests that you complete the enclosed application. Please complete the application, sign, date, and mail it to the (2) agency in the enclosed pre-addressed envelope.

If you have any questions about your claim for (3) pension, contact the (4) agency at the address shown on the pre-addressed envelope we provided. That agency will send you a letter when they make a decision on your claim.

1. Adjective form of country

2. Same as 1

3. Same as 1

4. Same as 1

E. Securing Foreign Earnings Records and Stalls

17050 NOTIFICATION THAT ONLY U.S. EARNINGS HAVE BEEN USED IN THE DECISION   (a)   is based only on work covered by the U.S. Social Security system. We cannot consider work covered by   (b)   until we receive a record of   (c)   earnings from that country.

(a)

This decision, the decision you have received on your claim

(b)

Country of agreement

(c)

your, your husband's, your wife's, etc.

17051 NOTIFICATION THAT THE FOREIGN EARNINGS RECORD WILL BE REQUESTED

When we have all of the information required for your totalization claim we will forward it to   (a)   and ask them to furnish us with information about the work credited to   (b)   record under their social insurance system.

(a)

Country of agreement

(b)

your, your husband's, your wife's, etc.

17052 CLAIMANT WILL BE INFORMED WHEN APPLICATION IS SENT TO THE FOREIGN AGENCY

You will be notified when we have forwarded your application to the appropriate   (a)   agency.

(a)

Country of agreement

17053 DECISION REFERS ONLY TO U.S. BENEFITS UNDER TOTALIZATION

This decision refers only to your application for U.S. Social Security benefits under the international agreement.   (a)   will notify you about your eligibility for benefits under its laws.

(a)

Country

17054 APPLICATION IS ALSO A FOREIGN APPLICATION

Your application for benefits under the international agreement is also a claim for Social Security benefits from   (a)   .

(a)

Country of agreement

17055 NOTIFICATION THAT THE FOREIGN EARNINGS RECORD HAS BEEN REQUESTED

We requested your work record from (1). We will use your work record from that country and the United States to decide if you qualify for benefits. As soon as we receive your work record, we will let you know about your claim for U.S. benefits.

1. Name of country

17056 NOTIFICATION THAT CLAIMS PACKAGE SENT

We sent your totalization application to   (a)   on   (b)    . We also requested your   (c)   earnings record.

(a)

Name of Country

(b)

Date

(c)

Name of Country

17057A FOREIGN APPLICATION HAS BEEN SENT

We forwarded the application to the agency shown below:

(1)

If you have any questions about this claim, please contact the (2) office shown above. That agency will contact (3) if they need more information. They will process your claim for a pension and will notify (4) when they make a decision on your claim. That agency will not send their decision to us; so we will not be able to give you more information about this claim.

1. Foreign agency name and address

2. Adjective form of country

3. A=you
   B=the claimant

4. Same as 4

17057B DATA FROM FOREIGN APPLICATION HAS BEEN SENT

We have notified   (a)   about your application.

(a)

Name and address of foreign agency

17058 EARNINGS RECORD REQUESTED — SPECIFIC DELAY

Our experience with the social insurance agencies in   (a)   indicates it will take at least   (b)   months to obtain the work record. As soon as it is received, we will notify you of our decision on your claim for benefits under the international agreement.

(a)

Name of Country

(b)

Number of months

17059 GENERAL DELAY

Since we are experiencing longer delays than anticipated, we are unable to give you a definite date for the completion of your claim. We will notify you of our decision as soon as the information we requested from   (a)   is received.

(a)

Name of Country

17060 NOTIFICATION THAT REGULAR U.S. SOCIAL SECURITY BENEFITS WILL CONTINUE

Your entitlement to regular Social Security benefits will continue. Those benefits will not be affected by the totalization application you have filed.

17061 FOREIGN GOVERNMENT WILL NOTIFY THE CLAIMANT ABOUT APPLICATION FOR FOREIGN BENEFITS

  (a)   will notify you directly by mail concerning your eligibility for benefits under its laws once the appropriate agency has reached a decision.

(a)

Country of agreement

17062 REFERRAL OF CLAIMANT TO THE FOREIGN AGENCY FOR STATUS OF FOREIGN CLAIM

Any questions regarding your claim for benefits from   (a)   should be sent directly to the social insurance agency handling your claim in that country. The name and address of the agency is as follows:   (b)  

(a)

Country of agreement

(b)

Name and address of the proper foreign agency

F. Denials

17070 DENIAL — LESS THAN SIX QC's

To be eligible for U.S. benefits under an international agreement, a worker must first have at least six U.S. quarters of coverage.

Our records show   (a)   earned   (b)   quarters of coverage under the U.S. Social Security system. Therefore, you are not eligible for benefits from the U.S. under the agreement with   (c)   .

(a)

you have, the worker had, etc.

(b)

number of quarters

(c)

country

17071 DENIAL — INSURED STATUS STILL NOT MET AFTER INCLUDING FOREIGN EARNINGS

We have received the information we requested about your earnings in   (a)   . Based on your combined U.S. and   (b)   coverage, you have not worked long enough to qualify for benefits from the U.S. To qualify, you need credit for   (c)   calendar quarters of work. Our records indicate that you now have   (d)   quarters based on    (e)   coverage and   (f)   quarters based on U.S. coverage for a combined total of only   (g)   quarters. Therefore, no benefits are payable by the U.S. under the international agreement.

(a)

country

(b)

country

(c)

number

(d)

number

(e)

country

(f)

number

(g)

number

17072 EARNING ADDITIONAL QC'S

The enclosed pamphlet explains how a person earns Social Security work credits. If you return to work and earn the additional quarters that you need, please contact the nearest   (a)   as soon as possible to file a new claim.

Enclosure: HEW (SSA) 05-10072

(a)

Social Security Office, U.S. diplomatic or consular office

17073 DENIAL — ENTITLED TO RSDI BENEFIT

Under the agreement, the U.S. cannot give credit for covered work earned under the   (a)   social insurance system if a benefit is payable by the U.S. based only on work covered by its own Social Security system. Since you are eligible for a benefit from the U.S. based only on your    (b)   U.S. coverage, you are not eligible for any additional benefits from the U.S. based on coverage earned in   (c)   .

(a)

country

(b)

own, husband's, wife's, etc.

(c)

country

17074 DENIAL BASED ON APPLICATION FILED WITH FOREIGN COUNTRY

There is an international Social Security agreement in effect with    (a)   . Under the terms of this agreement, a claim filed with that country is also a claim for U.S. benefits, and we are required to tell you whether or not you are entitled to benefits from this country.

  (b)   has notified us that you filed a claim for   (c)   benefits on   (d)   .

(a)

country

(b)

country

(c)

retirement, survivor's

(d)

date

17075 DENIAL — UNRESTRICTED TOTALIZATION APPLICATION — CLAIMANT NOT YET RETIREMENT AGE

Based on the date of birth you gave, you are not old enough to be entitled to U.S.   (a)   benefits or to any other benefit from the U.S. at this time. When you reach age   (b)   , you may wish to file a claim with this country.

(a)

retirement, survivors

(b)

62, 60

17076 DENIAL OF REGULAR U.S. AUXILIARY BENEFITS ON TOTALIZATION NOTICESYour   (a)   not eligible for   (b)   benefits payable by the U.S. because   (c)   .

(a)

wife is, husband is, child is, children are, parents are, etc.

(b)

spouse, child's, student, parent's, etc.

(c)

he/she is not yet age 62, he/she is over age 19, etc.

17077 DENIAL OF U.S. AUXILIARY TOTALIZATION BENEFITS

For this reason, your   (a)   cannot qualify for U.S. totalization benefits on   (b)   record either.

(a)

spouse, child, husband, etc.

(b)

your, this, your husband's, etc.

17078 DENIAL OF U.S. TOTALIZATION BENEFITS — FAILURE TO MEET DISABILITY REQUIREMENTS OF THE LAW

Since you do not meet the disability requirements of the law, the U.S. cannot pay benefits under the international agreement with   (a)   . An international Social Security agreement does not change a country's requirements for entitlement to benefits. Each country must determine a claimant's entitlement based on its own laws.

Enclosure: HEW (SSA) 10058

(a)

country

17079 DENIAL OF U.S. TOTALIZATION BECAUSE THE FOREIGN EARNINGS WERE UNDER DUAL COVERAGE

We find that   (a)   work for the period   (b)   under the   (c)   Social Security system was also covered by the U.S. Since the U.S. system has already given credit for that work, no additional credit may be granted for   (d)   coverage of the same work.

(a)

your, the wage earner's

(b)

show dates

(c)

country of agreement

(d)

country of agreement

17080 DENIAL OF U.S. TOTALIZATION BENEFITS BECAUSE THE FOREIGN EARNINGS WERE BEFORE 1937

We find that   (a)   work for the period   (b)   , covered by the   (c)   system, was performed before Social Security coverage became effective in the U.S. in 1937. Therefore,   (d)   Social Security work credits earned before 1937 cannot be used to establish eligibility for U.S. benefits.

(a)

your, the wage earner's

(b)

show dates

(c)

country of agreement

(d)

country of agreement

17081 DENIAL OF U.S. TOTALIZATION BENEFITS BECAUSE FOREIGN EARNINGS WERE FROM VOLUNTARY COVERAGE OR EXCUSED PERIODS

The Social Security credits   (a)   earned under the   (b)    system for the period   (c)   were for   (d)   . Under the terms of the Social Security agreement with   (e)   , the U.S. cannot give credit for   (f)   when determining your    (g)   under the U.S. system.

(a)

you, the worker

(b)

country of agreement

(c)

show dates

(d)

Italy - Voluntary coverage

FRG - excused periods of coverage (AUSFALLZEIT)

Switzerland - Coverage requiring no work

(e)

country of agreement

(f)

same as “(d)”

(g)

eligibility for benefits, benefit amount

17082 DENIAL OF U.S. TOTALIZATION BENEFITS BECAUSE THE FOREIGN COUNTRY WAS UNABLE TO LOCATE ALLEGED EARNINGS

We asked the Social Security agency of   (a)   for information about   (b)   coverage in that country. However, the agency was unable to locate a record of   (c)   work for the period   (d)    . Therefore, we cannot grant credits for this period.

(a)

country of agreement

(b)

your, the worker's

(c)

your, his, her

(d)

show dates

17083 DENIAL OF U.S. BENEFITS FOR A BROTHER OR SISTER FILING UNDER AN INTERNATIONAL AGREEMENT

We cannot pay benefits to you on the record of   (a)   because the U.S. Social Security law does not provide for benefits for a   (b)   of a worker. Therefore, your claim for benefits is denied.

(a)

name of worker

(b)

brother, sister

17084 DENIAL — WORK IN FOREIGN COUNTRY NOT COVERED

We have now received the information that we had requested about your work in   (a)   . The social insurance agency there has informed us that your work was not covered under its compulsory insurance program. Therefore, we cannot grant credits for any period of work in   (b)   .

(a)

country

(b)

country

17085 DENIAL — FOREIGN COUNTRY CERTIFIES NO EARNINGS — FOREIGN EARNINGS ALLEGED BEFORE 1937

Information we received from   (a)   does not show that    (b)   had any Social Security coverage there after 1936. Although    (c)   may have had coverage there before 1937, it cannot be used to establish eligibility for U.S. benefits.

(a)

country

(b)

you, the worker

(c)

you, he/she

G. HI/SMI

17090 FOREIGN COVERAGE CANNOT BE USED TO ESTABLISH HI ENTITLEMENT — GENERAL

Only U.S. Social Security credits can be used to establish entitlement to Medicare hospital insurance benefits. This is true even if monthly benefits may be payable based on combined work credits from both countries. Therefore, if   (a)   not worked long enough under the U.S. Social Security system, under the regular provisions of the law, you cannot be entitled to hospital insurance.

(a)

you have, the worker has, the worker had (Add paragraph MH07 if inquirer is a U.S. resident)

17091 HI/SMI INFORMATION FOR SPOUSE, WIDOW OR WIDOWER

Should you earn an additional   (a)   quarters of coverage on your own Social Security record, you may be eligible for premium-free Medicare hospital insurance benefits   (b)   . However, to obtain these benefits, you must complete an application and meet certain other requirements. Contact any Social Security office   (c)   for an application and further information.

(a)

number of additional QC's needed

(b)

When the beneficiary is under age 65, add: “at age 65.” Otherwise omit this fill-in

(c)

If the claimant lives outside the U.S., add: “or your nearest U.S. consular or diplomatic office.” Otherwise, omit this fill-in

17092 HI/SMI INFORMATION FOR TOTALIZATION BENEFICIARY WHO IS A U.S. RESIDENT UNDER AGE 65

The Social Security Act does not provide for automatic enrollment in Medicare at age 65 for individuals who become entitled to monthly benefits on the basis of combined U.S. and foreign coverage. Since your benefits are based on U.S. and foreign coverage, you will need to file an application if you wish to enroll in Medicare. Contact any Social Security office about 3 months before you reach age 65 for an application and further information.

17093 HI/SMI DENIED — TOTALIZATION BENEFICIARY IS AGE 65 OR OLDER OR HAS BEEN ENTITLED TO DISABILITY BENEFITS FOR A CONTINUOUS PERIOD OF AT LEAST 24 MONTHS

Your claim for Medicare hospital insurance benefits has been denied because   (a)   needed   (b)   U.S. Social Security quarters of coverage but only had   (c)   quarters. Social Security work credits earned in another country cannot be used to help establish eligibility for hospital insurance, even though monthly benefits may be payable based on work credits from both countries.   (d)  

(a)

you, the worker

(b)

number of QC's needed

(c)

number of QC's earned in the U.S.

(d)

If applicable, add the following paragraph. Otherwise, omit the fill-in: “Because you are not entitled to hospital insurance, you cannot receive supplemental medical insurance either.”

17094 DEEMED INSURED HI

Even if   (a)   do(es) not meet the regular work requirements for hospital insurance, you may be eligible for these benefits under a special provision of the law which applies only to persons who attained age 65 before 1975. To qualify, you must have earned, on your own record, at least 3 quarters of coverage for each year elapsing after 1966 and before the year you became age 65. You must also meet certain other requirements. Since you became age 65 in   (b)   , you would need   (c)   quarters of coverage.

If you earn   (d)   additional quarters of coverage, contact any Social Security office for an application and further information.

(a)

you, the worker

(b)

year of attainment of age 65

(c)

number of QC's needed for deemed insured HI

(d)

number of additional QC's needed

H. Close-Out and Recon

17100 NO FURTHER BENEFITS PAYABLE BY THE U.S.

In addition, you are not entitled to any other benefits from the U.S. based on the application you filed.

17101 NO FURTHER BENEFITS PAYABLE BY THE U.S. WITHOUT THE INCLUSION OF FOREIGN EARNINGS

In addition, you are not entitled to any other benefits from the U.S. based on the application which you filed considering only   (a)   U.S. earnings.

(a)

your, your father's, your husband's, the worker's, etc.

17102 NO FURTHER BENEFITS PAYABLE BY THE U.S. WITH THE EXCEPTION OF TOTALIZATION BENEFITS

In addition, you are not entitled to any other benefits from the U.S. based on the application you filed with the possible exception of benefits based on combined coverage from both countries. As soon as a determination is made on your entitlement to these benefits, you will be notified of the decision.

17103 RECONSIDERATION PARAGRAPH USING TOTALIZATION'S ADDRESS

If you believe that this determination is not correct, you may request that your case be reexamined. If you want this reconsideration, you must request it not later than 60 days from the date you receive this notice. You may make your request directly to the Social Security Administration, P.O. Box 17049, Baltimore, Maryland 21235, U.S.A. or through   (a)   . If additional evidence is available, you should submit it with your request.

(a)

the nearest U.S. diplomatic or consular office, any Social Security office

I. Closing Paragraphs

17110 REFERRAL TO DO OR FSP

I hope this information is helpful. If you need further assistance, contact the nearest   (a)   or this office. If you visit an office, please take this letter with you.

(a)

Social Security office; U.S. diplomatic or consular office

17111 FINDING THE ADDRESS AND PHONE NUMBER OF DO

You can find the address and telephone number of the Social Security office nearest you by looking in the telephone directory under “Social Security Administration.”

17112 ALPHA INQUIRY

When contacting us in the future, please include your U.S. Social Security number.

17113 REFERRAL TO DO

If you have any questions about your claim, contact any Social Security office. Most questions can be handled by telephone or mail. If you visit an office, however, please take this letter with you.

J. Alien Nonpayment

17120 ALIEN NONPAYMENT

A beneficiary who is not a U.S. citizen cannot be paid monthly benefits after he has been outside the U.S. for 6 full consecutive calendar months unless certain conditions are met. These conditions are explained in the enclosed booklet. However, the international agreement with   (a)   provides for payment to a beneficiary who is a resident of that country, even though the beneficiary does not meet any of these conditions. Since payment of benefits depends on residence in   (b)   , you should let us know immediately if   (c)   leave(s) there.

Enclosure: HEW Pub. No. (SSA) 05-10137

(a)

country of agreement

(b)

country of agreement

(c)

you, the person for whom you receive benefits

17121 CLAIMANT IS USING A BANK ADDRESS

To administer the provisions of the Social Security agreement with    (a)   , the Social Security Administration must know each beneficiary's country of residence at all times. Therefore, you should notify us immediately if there is any change in   (b)   .

(a)

country of agreement

(b)

your home address, the home address of the person for whom you receive benefits

K. Paragraphs Specific to the Italian Agreement

17130 REGULAR U.S. SOCIAL SECURITY BENEFITS WILL CONTINUE — ITALIAN TOTALIZATION CLAIM PENDING

In the meantime, your entitlement to regular Social Security benefits will continue.

17138 GENERAL EXPLANATION OF THE CHOICE OF BENEFITS UNDER THE INTERNATIONAL AGREEMENT WITH ITALY

Under the Social Security agreement with Italy,   (a)   may choose to receive from the U.S. either a regular Social Security benefit based on U.S. earnings alone, or a totalization benefit based on combined U.S. and Italian earnings. An individual may receive only one type of benefit but not both.

The amount chosen applies only to benefits payable by the U.S. Italy will make a decision about benefits payable under its laws and will send a separate notice.

(a)

you, the worker's survivors

17139A ELECTION NOTICE — ITALIAN EARNINGS RECORD RECEIVED — LOWER BENEFIT APPLIES

After receiving   (a)   Italian work record, we determined you would be eligible for a benefit of   (b)   effective   (c)   based on combined earnings from both countries. This amount is less than the regular Social Security benefit you now receive because it is prorated based on the proportion of work performed under the U.S. Social Security system. The enclosed pamphlet explains how benefits based on combined earnings are determined.

Enclosure: HEW Pub. No. (SSA) 05-10171

(a)

your, the worker's

(b)

amount

(c)

date

17139B ELECTION — CHOICE OF LOWER U.S. TOTALIZATION BENEFIT

Even though the benefit based on the combined earnings is less than your regular Social Security benefit, you may choose to receive the smaller benefit, if you wish.   (a)  

(a)

Insert one of the following sentences:

1. Life Case

   However, if you do choose the lower amount, the benefits of any other person entitled on your record must also be reduced.

2. Death Case

   However, in order for you to receive the lower amount, any other persons entitled to benefits on the deceased worker's record must also choose the lower amount.

17139C ELECTION — RESPONSE IF LOWER BENEFIT ELECTED

If you choose to receive the lower benefit, you must notify us within 3 months of the date you receive this notice. Otherwise, we will assume that you wish to continue receiving the higher benefit and will consider that decision final.

17140 ELECTION — TOTALIZATION BENEFIT LOWER BUT EARLIER MONTH OF ENTITLEMENT

From   (a)   through   (b)   you were entitled only to a benefit based on combined earnings. In   (c)   you had earned enough quarters of coverage to be entitled to a regular U.S. benefit of    (d)   . Therefore, effective   (e)   you may choose to receive your current regular U.S. benefit or the lower benefit based on combined earnings. However, if you choose the lower amount, the benefit of any other persons entitled on your record must also be based on the lower benefit.

(a)

date

(b)

date

(c)

date

(d)

amount

(e)

date

17141 ELECTION — BENEFITS FROM ITALY

The Italian social insurance agency has figured benefits it can pay, considering both U.S. and Italian earnings. It has asked us to inform you of these amounts and have you elect which benefit you want to receive. The regular Italian pension is lire   (a)   , effective   (b)   . The Italian totalization pension (after combining U.S. and Italian earnings) is lire   (c)   , effective   (d)   .

(a)

amount

(b)

date

(c)

amount

(d)

date

17142 ELECTION — EFFECT OF GUARANTEED MINIMUM

If your choose the Italian totalization pension of lire   (a)   , your U.S. totalization benefit will be raised to   (b)   . The reason for this increase is because of a special provision in the agreement with Italy. This provision ensures that beneficiaries residing in the U.S. do not receive less than the minimum benefit payable by the U.S. for regular Social Security benefits. Theminimum payable is   (c)   effective   (d)   . Therefore, the total of the U.S. totalization benefit and the Italian totalization pension cannot be less than this figure.

(a)

amount (optional fill-in: and the U.S. totalization benefit of           effective           )

(b)

amount

(c)

amount

(d)

date

17143 COMPLETION OF ELECTION FORM FOR U.S. BENEFITS

Please indicate on the enclosed election form the benefit amount you wish to receive from the U.S.

Enclosure: Election Form

17144 COMPLETION OF ELECTION FORM FOR U.S. AND ITALIAN BENEFITS

Please indicate on the enclosed election form your choice of benefits from both the U.S. and Italy. Sign the form and return it to this office in the enclosed envelope within 90 days of the date of this notice. Upon receipt of the form, your choice of a U.S. benefit will be acted upon by this office. Your choice of a benefit from Italy will be forwarded to the Italian agency. Italy will then begin payment of the benefit amount you have chosen.

Enclosures: Election Form, Return Envelope

17145 COMPLETION OF ELECTION FORM FOR ITALIAN BENEFITS

Please indicate on the enclosed election form your choice of benefit from Italy. Sign the form and return it to this office in the enclosed envelope within 90 days of the date of this notice. Upon receipt of the form, your choice will be   (a)   forwarded to Italy. Italy will then begin payment of the benefit amount you have chosen.

(a)

OPTIONAL FILL-IN: acted upon by this office and

Enclosures: Election Form, Return Envelope

L. Paragraphs Specific to the German Agreement

17170 GERMAN INQUIRY — CLAIMANT ALREADY ENTITLED TO GERMAN BENEFITS

The German social insurance agencies will use U.S. Social Security coverage only to establish eligibility to benefits; that is, to meet the 5, 15 or 35 year coverage requirements. They will not use U.S. earnings to initially calculate or increase the German pension amount. Since you are already entitled to German social insurance benefits based on German coverage alone, the use of U.S. coverage by a German agency would not appear to be advantageous since your eligibility to German benefits has already been established and the U.S. earnings would not be used to increase your German benefit.

This is not a formal determination concerning your eligibility to, or the amount of, your German pension. That can be made only by a German agency. If you want such a determination, you may either file an application with any U.S. Social Security office, or write to the German agency having jurisdiction of your previous claim.

17171 FORWARDING APPLICATION FOR RETROACTIVE VOLUNTARY CONTRIBUTIONS TO THE GERMAN AGENCY

You may forward your application for retroactive voluntary contributions directly to the appropriate German insurance agency listed in your Special Guide or to this office. If you send the forms to this office, we will forward them to Germany.

17172 REFERRAL TO THE GERMAN AGENCY REGARDING FILING FOR CURRENT CONTRIBUTIONS

If you wish to make current voluntary contributions, please contact the German agency directly. The U.S. Social Security offices do not stock forms for this purpose. I suggest that you review the information concerning voluntary contributions in the dark green brochure and the information in the Sondermerkblatt (Special Guide). To make current voluntary contributions you should write directly to the appropriate German agency listed in the brochure.

Enclosures: SSA 05-10715, Sondermerkblatt (Special Guide)

17173 REFERRAL TO THE D/USA-13

Form D/USA-13, application for (1) retroactive voluntary contributions for the period from October 1972 through November 1979, or (2) the repayment of contributions previously refunded between October 1972 and November 1979, and a Special Guide providing detailed instructions are enclosed.

Enclosure: D/USA-13 and Special Guide

17174 CLAIM FORWARDED TO BFA

Your application under the agreement has been forwarded to:

Bundesversicherungsanstalt

fur Angestellte

Postfach

1000 Berlin 88

WEST GERMANY

They will notify you of their decision on your claim.

17175 CLAIM FORWARDED TO LVA

Your application under the agreement has been forwarded to:

Landesversicherungsanstalt
Freie und Hansestadt Hamburg
Uberseering 10
2000 Hamburg 60
WEST GERMANY

They will notify you of their decision on your claim.

M. Paragraphs Specific to the Agreement With Switzerland

17180 REFERRING SWISS NATIONALS TO CONSULAR OFFICE

Additional information is required in order to complete your claim for benefits under the international Social Security agreement between the U.S. and Switzerland. Additional forms must be completed to file for Swiss benefits. These forms may be obtained from any of the Swiss consular offices listed on the attachment. The completed form should be returned to the consular office or mailed directly to the Swiss Compensation Fund, Av. Ed. Vaucher 18, 1211 Geneva 28, Switzerland.

Enclosure: List of Swiss Consular Offices

17181 COMPLETION OF CH/USA 2.1, 2.2 AND/OR 2.3

Additional information is required in order to complete your claim for benefits under the international Social Security agreement between the U.S. and Switzerland. Please complete the enclosed Swiss application and return it in the enclosed envelope.

The form should be completed whether or not you are a U.S. citizen.

Enclosure: Application Form

17182 FOLLOW-UP REQUEST FOR CH/USA 2.1, 2.2 AND 2.3

Please refer to our letter dated   (a)   .

Before further action may be taken on your claim for benefits under the international agreement with Switzerland, you must complete the Swiss application that was enclosed. Since you may have misplaced the original form, we are enclosing another application and return envelope.

If you have decided not to pursue your claim for benefits under the international agreement, please notify us of your decision.

Enclosure: Application Form, Return Envelope

(a)

date

17183 CLAIM FORWARDED TO CSC

Your application under the agreement has been forwarded to:

Caisse Suisse De Compensation
Av. Ed. Vaucher 18
1211 Geneva 28, Switzerland

They will notify you of their decision on your claim.

N. Paragraphs Specific to the Canadian Agreement

17190 EFFECTIVE DATE — CANADA

The Social Security agreement between the U.S. and Canada was signed on March 11, 1981. A supplementary Administrative Arrangement designed to implement the Agreement was signed on May 22, 1981. Both the Agreement and Arrangement will be subject to review by the Congress of the U.S. and Canada's Parliament. Thus, we expect the Agreement will not go into effect before late 1984.