Forms

CROATIA

Form HR/CZ 202

Please fill in the application and return it to the institution mentioned below or to its nearest local office to the following address:

Hrvatski zavod za mirovinsko osiguranje –Središnja služba
Antuna Mihanoviča 3
10000 Zagreb, CROATIA
Tel.:+385 1 4595-500
http: www.mirovinsko.hr

Where appropriate the institution will contact you for any missing information or documentation.Once your application is complete, it will be forwarded it to CSSA.

IZRAEL

Form IZR-CZ

Please fill in the application and return it to the institution mentioned below or to its nearest local office to the following address:

National Insurance Institute
Liaison Office for International Conventions
13, Weizmann Avenue
P.O.Box 90009
91909 Jerusalem, ISRAEL
E-mail: btlfeed@btl.gov.il
http: www.btl.gov.il

Where appropriate the institution will contact you for any missing information or documentation.Once your application is complete, it will be forwarded it to CSSA.

CANADA

Form CAN-CZ 1 (czech-french version)
Form CAN-CZ (czech-english version)

Please fill in the application and return it to the institution mentioned below or to its nearest local office to the following address:

International Operations
Income Security Programs
Human Resources Development Canada
15th floor, Tover B
355 North Riiver Road
Ottawa, Ontario K1A 0L4
CANADA
Tel.: 1 613 957-1954
E-mail: isp-psr.mail-poste@hrsdc-rhdsc.gc.ca
http: www.rhdcc-hrsdc.gc.ca

Where appropriate the institution will contact you for any missing information or documentation.Once your application is complete, it will be forwarded it to CSSA.

QUÉBEC

Form QUÉ-RTC 3

Please fill in the application and return it to the institution mentioned below or to its nearest local office to the following address:

Bureau des ententes de sécurité sociale
Régie des rentes du Québec
1055, boul. René-Lévesque est, 13e étage
Montréal (Québec)
Canada H2L 4S5
Tel.: (514) 866-7332
E-mail: isp-psr.mail-poste@hrdc-drhc.gc.ca
http: www.rrq.gouv.qc.ca

Where appropriate the institution will contact you for any missing information or documentation.Once your application is complete, it will be forwarded it to CSSA.

USA

Form CZ/USA 202

Send the form filled-in with block letters or electronically to the below-mentioned institution or its regional office depending on your place of residence:

U.S. Social Security Administration
OIO –Totalization
P.O. Box 17769
Baltimore, MD 21235-7769
U.S.A.
www.ssa.gov

The American party will consequently send your application for Czech pension benefits along with the proof of your insurance periods in the USA to the Czech Social Security Administration to Prague. If necessary, the Administration will ask you to provide more information.

CROATIA

Form CZ/HR 202

Please fill in the application and return it to the institution mentioned below or to its nearest local office to the following address:

Č SSZ Praha
Křížová 25
225 08 Praha 5
Tel.: 00420 257 061 111
E –mail: posta@cssz.cz

Where appropriate the institution will contact you for any missing information or documentation.Once your application is complete, it will be forwarded it to Croatian Institution for social security.

USA

Form  SSA 2490 –BK
Translation of Form SSA 2490 –BK into Czech. 

Please, fill-in the form Application for Benefits under a U.S. Agreement with block letters or electronically and attach also the filled-in supplement ”Supplement to Claim for U.S. Benefit (WZ0-CZ-01)” to it. Please, do not fill-in the Czech translation of Form SSA 2490 –BK, since it shall only make understanding of the original English form SSA 2490 –BK easier for you. Hand in the filled-in forms at the respective office of the Regional Social Security Administration or in Prague at the Prague Social Security Administration. This institution will forward your application for pension benefits to

ČSSZ
Křížová 25
225 08 Prague 5
Tel.: 00420 257 061 111
E –mail: posta@cssz.cz

ČSSZ (Czech Social Security Administration) will attach the proof of your insurance periods in the Czech Republic and after filling-in any other necessary information all documents will be sent to the American insurance institution. The American insurance institution or its contact office for the central Europe in Warsaw (Federal Benefits Unit Warsaw) can contact you (in writing, by telephone or e-mail) in case it will be necessary to provide more details or some other information.