Effective Dates: 08/29/2013 - Present Previous | Next

Basic (09-02)

GN 01744.220 Completing the U.S. - Australian Agreement on Social Security Transmittal/Request/Certification Form (SSA-2960-AUS)

A. When to use

The SSA-2960-AUS is completed in the totalization module in OIO or by VARO in Manila. It is used to:

  • •

    Transmit claims and related material to Centrelink

  • •

    Request information from Centrelink, and

  • •

    Respond to requests from Centrelink.

B. Description of form

This is an electronic form and can be located, completed and printed by accessing the Totalization Data Collection Program (TDCP).

C. Procedure

Follow these instructions to complete the items on the form. Be sure to check the appropriate address information in the “FROM” block.

1. Information about the claim

Complete the items in Part 1 as follows:

a. Item A

Always enter the first and last names of the worker.

b. Item B

Always enter the maiden name if the worker is a married woman. Enter the name at birth for a man, if it is different.

c. Item C

Check the appropriate sex of the worker.

d. Item D

Always enter the Australian Customer Reference Number (CRN) if the number is shown on the application or on the Australian liaison form.

e. Item E

Always enter the worker's U.S. SSN.

f. Items F, G, and H

Always enter the complete name, maiden name, and U.S. SSN of the claimant if the claimant is not the worker entered in Item A.

g. Item I

Always enter the complete address and telephone number of the claimant.

h. Item J

On initial claims packages, indicate the type of claim for U.S. benefits and/or Australian benefits in the appropriate columns.

i. Item K

Enter the filing date being certified to Centrelink on all initial claims packages or in response to Centrelink's request for the filing date.

2. Certification of data

Complete the Certification of Data part of the form only when transmitting a claim for Australian benefits in response to Centrelink's request for specific information. If the requested information is not available, indicate “unknown.” If the requested information is known but is not verified in SSA records, enter the information but do not check the “Verified” block.

a. Item A – name and date of birth

  • •

    Enter the names of all claimants and in survivor cases, the name of the deceased worker. Enter the first and last names and, if applicable, the maiden name.

  • •

    Enter the date of birth for all claimants and, if applicable, for the deceased worker.

  • •

    Check the “Verified” block if the date of birth has been used to award U.S. benefits, or the date is shown on the MBR as proven

b. Item B – worker/contributor's date of death

Enter the deceased worker's date of death in survivor claims. Check “Verified” if the date has been used to award U.S. benefits or the date is shown on the MBR as proven.

c. Item C – date of marriage

Enter the date of marriage if a spouse or widow(er) is claiming benefits. Check “Verified” if the data has been used to award U.S. benefits or the date is shown on the MBR as proven.

d. Item D – date of divorce

Enter the date of divorce if a divorced spouse or widow(er) is claiming benefits. Check “Verified” if the data has been used to award U.S. benefits or the date is shown on the MBR as proven.

e. Item E – work ending date

Enter the date the worker stopped working.

f. Item F – country of birth

Enter the country of birth for the worker and the spouse, if applicable. Check “Verified” if the data has been used to award U.S. benefits or the date is shown on the MBR as proven.

g. Item G – citizenship

Enter the country of citizenship of the worker and the spouse, if applicable. Check “Verified” if the data has been used to award U.S. benefits or the date is shown on the MBR as proven.

3. Certification of benefit data

Enter the name of the worker and/or other claimants, type of U.S. benefit being received, the effective date (month of entitlement or October 2002, whichever is later), and the monthly amount. Include all changes in the monthly benefit amount from the effective date.

4. Information provided

If you are sending an initial claims package or responding to an assistance request, check all appropriate blocks to indicate the type of material being sent to Centrelink. Check item:

a. Item A

If attaching the U.S. coverage record.

b. Item B

If attaching Australian Applications [AUS/USA-4 and/or Mod (i)].

c. Item C

If attaching Australian Work Ability Form (form WA).

d. Item D

If attaching medical evidence submitted by the claimant or from SSA files.

e. Item E

If responding to a request from Centrelink. Indicate the date of Centrelink's request.

f. Item F

If attaching material not covered by any block shown. Briefly explain the attachment in the space provided for “Remarks.”

 

5. Information needed

If you are requesting information under the Agreement, check “Yes.” If you answer “No,” attach a consent statement. Check:

a. Item A

If requesting a record of Australian working life residence periods. Indicate the number of “Quarters Needed” for U.S. totalization insured status.

b. Item B

If requesting a copy of medical evidence from Centrelink's files.

c. Item C

If following up on an earlier request to Centrelink. Show the date of the original request.

d. Item D

If requesting information not covered by items A-C shown above. Briefly explain the request in the space provided for “Remarks.”

6. Remarks

Keep remarks to a minimum and make them clear and concise. Do not use technical jargon or abbreviations. Use this space to enter additional monthly benefit amounts if necessary. Be sure to enter your name in the signature block.

D. Reference

Facts about the Australian Customer Reference Number (CRN), GN 01744.315

 

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0201744220
GN 01744.220 - Completing the U.S. - Australian Agreement on Social Security Transmittal/Request/Certification Form (SSA-2960-AUS) - 08/29/2013
Batch run: 10/17/2016
Rev:08/29/2013