The SSA-e2960-BE is completed in the DIO modules in DIO and the Federal Benefits Unit in the London, England to:

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  transmit claims and related material to the Belgian agencies,

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  request information from the Belgian agencies, and

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  respond to assistance requests from the Belgian agencies.

Blocks for verifying dates and certifying monthly benefits are completed only by DIO.

The Form SSA-e2960-BE is an electronic form that is only available via the TDCP.

Use the following procedure to complete the items on the form. Some items on the form must be completed in all cases. Some additional items must be completed when the form is used to transmit a claim for Belgian benefits or when the form is used to respond to an assistance request from a Belgian agency.

1. 1. 

   General Information

   Refer to POMS GN 01714.025 to determine the proper agency.

2. 2. 

   Part I - Information About the Claim

   Always complete items A, B, and D.

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     Item A - Enter the first and last name of the worker. If applicable, also show the worker's maiden name in the Remarks box.

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     Item B - Enter the worker's U.S. Social Security Number.

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     Item D - Enter the worker's Belgian social insurance number as it is shown on the application or on the Belgian liaison form. If unknown, enter “unknown”.

   Complete items C, E, F, and G if you are transmitting a claim or protective filing date to the Belgian agency.

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     Item C - Enter the claimant's name only if the claimant is not the worker. Always enter the claimant's address.

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     Item E - Indicate the type of Belgian benefits that are being claimed.

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     Item F - Enter the filing date to be certified to the Belgian agency. Enter the “date benefit elected” and “date work ceased” if the dates are shown on the application Form SSA-2490-F4.

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     Item G - Enter the name and address of the Belgian sickness fund if shown on the application Form SSA-2490-F4.

3. 3. 

   Part II - Certification of Data

   Always complete the following items in this part of the form.

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     Worker's Name at Birth - Enter the first, middle and last name at birth.

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     Spouse or Widow's Full Name - Enter the full name, including the maiden name of all claimants. Example: If Mary Ann Jenkins married Mr. Thompson, show her name as Mary Ann Jenkins Thompson.

   • •

     Children's Names - Enter the first, middle and last names of all claimants.

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     Dates of Birth - Enter the date of birth for the worker and all claimants. Check the verified blocks if the dates have been used to award U.S. benefits; or if they are shown on the MBR as proven.
      
     Complete the following items in this part of the form if you are transmitting a claim to the Belgian agency or if the items are needed to respond to a request from the Belgian agency.

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     Citizenship - Enter the citizenship shown on the application for the worker and for the spouse or widow.

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     Beginning of Incapacity - Enter the date if it is shown on the application Form SSA-2490-F4. Check the “verified” block if the worker is entitled to SSA disability benefits; and the Date of Disability Onset (DDO) on the MBR Agrees with the date alleged for the beginning of incapacity.

   • •

     Date of death, marriage and divorce - Enter the dates when they are applicable. Check the verified blocks if the dates have been used to award U.S. benefits; or if they are shown on the MBR as proven.

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     Belgian Social Insurance Number of Widow - Enter the widow's Belgian number if it is shown on the application Form SSA-2490-F4. If the number is unknown, enter “unknown”.

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     Children's Relationship to Worker - Enter the children's relationship that is shown on the application Form SSA-2490-F4. Do not complete the verified block.

4. 4. 

   Part III - U.S. Decision

   Complete the items in this part of the form if you are transmitting a claim to the Belgian agency or if the items are needed to respond to a request from the Belgian agency. For retirement and disability claims, complete this item for the worker. For survivor claims, complete this item for the widow.

   • •

     National - Check this block if regular RSDI benefits have been awarded.

   • •

     ART 10 - Check this block if totalization benefits have been awarded.

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     None - Check this block if no benefits have been awarded; e.g., the claim was denied, claim is still pending or no claim has been filed.

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     D.O.E. - Enter the first month and year in which a full benefit was paid or July 1, 1984, whichever is later.

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     Monthly Benefit - Enter the amount of the monthly benefit creditable (MBC) at the DOE that is shown.

5. 5. 

   Part IV - Material Attached

   Check the block that describes what is being sent to the Belgian agency.

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     Check A if attaching medical evidence submitted by the claimant or from SSA files.

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     Check B if attaching a U.S. coverage record.

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     Check C if attaching a request for an appeal of a Belgian decision.

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     Check D if attaching a statement about income.

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     Check E if no material is attached.

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     Check F if attaching material not covered by any block shown above and briefly explain the attachment.

6. 6. 

   Part V - Information Requested

   Check at least one block to indicate the type of material being requested from the Belgian agency.

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     Check A if you are not requesting any information.

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     Check B if you are requesting a Belgian coverage record. Do not enter a date.

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     Check C if you are requesting a copy of medical evidence from the Belgian agency's files.

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     Check D if you are following up on an earlier request to the Belgian agency and show the date of the request.

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     Check E if you are requesting information not covered by a block shown above. Briefly explain your request in “Remarks”.

7. 7. 

   Part VI - Remarks

   Keep remarks to a minimum and make them clear and concise. Never use jargon or abbreviations that are used only by SSA.