DIO completes this part of the form if a claim for Chilean benefits is being transmitted,
or if a Chilean agency has requested the information. For retirement or disability
claims, complete this section for the worker. For survivor claims, complete this section
for the widow and children. Information about the amount and effective date of the
benefit is only required for the widow.
Complete the items as follows:
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Pending, Denied, Awarded – check the appropriate block.
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Type of Benefit – enter “retirement, survivor or disability.
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Under the agreement – check “yes” if a totalization benefit is being paid; check “no”
if a fully insured benefit is being paid.
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Amount – enter the amount of the monthly benefit creditable (MBC) for the month in
which the SSA-2960-CHI is being completed.
NOTE: If the claimant is dually entitled on another Social Security record, enter only
the benefit amount paid on the worker's own record for retirement and disability claims.
For survivor claims, enter the total benefit amount that the widow receives.
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Effective Date – Enter the current month and year.