Effective Dates: 10/19/2023 - Present Previous | Next

Basic (10-23)

GN 01772.220 Completing the Form SSA e2960 USA/IS3 (U.S. – Iceland Agreement on Social Security Transmittal/Request/Certification)

A. Process for the SSA e2960 USA-IS3

The Division of International Operations (DIO) and the Oslo, Norway Federal Benefits Unit (FBU) complete the SSA-e2960 USA-IS 3 via the Totalization Data Collection Program (TDCP). Use the SSA-e2960 USA-IS 3 to:

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    transmit claims and related material to the Icelandic Liaison Agency;

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    request information from the Icelandic Liaison Agency; and,

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    respond to requests from the Icelandic Liaison Agency.

B. Procedure for completing the eForm SSA 2960 USA/IS 3

Use the following procedures to complete the items on the eForm SSA 2960 USA-IS3:

Item

Explanation

Date of Original field

Date automatically propagates

Date(s) of Follow-ups field

Follow-up date(s) automatically propagates

To field

Select the appropriate foreign agency

From Field

Office/Office Code and Fax numbers (if provided automatically propagate based on user's profile

1. Information about the claim

Complete the following information about the claim on the SSA-e2960 USA-IS 3:

a. Name of worker

Enter the first and last name(s) of the worker.

b. Name of worker at birth

Enter the worker's name at birth if it has changed.

c. Worker’s sex

Check the appropriate sex of the worker.

d. Iceland National Identification Number

Enter the Icelandic National Identification Number, if it appears on the application or on the Icelandic liaison form. If the claimant did not provide the Icelandic National Identification Number, indicate UNKNOWN in the Remarks field and provide the following information about the claimant:

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    given name,

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    surname,

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    date of birth, and

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    place of birth

e. Worker’s U.S. Social Security Number (SSN)

Enter the worker’s U.S. SSN.

f. Claimant’s name

Enter claimant’s name.

g. Claimant’s name at birth

If the claimant’s name has changed, enter the individual’s name at the time of birth.

h. Claimant’s U.S. SSN

Enter claimant’s U.S. SSN when he or she is not the worker entered in item A on the form.

i. Claimant’s address and telephone number

Enter the complete address and telephone number of the claimant.

j. Type of benefits claimed

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

k. Date claim filed

Enter the filing date certified to the Icelandic Liaison Agency on all initial claims packages or in response to the agency’s request for the filing date.

l. Certification of Data

Complete the Certification of Data part of the form only when transmitting a claim for Icelandic benefits, or in response to the Icelandic Liaison Agency’s request for specific information.

If the requested information is not available, indicate “unknown.” If our records do not verify the known requested information, enter the information but do not check the “Verified” block.

m. Name Birth/Name

Enter the names of all claimants and, in survivor cases, the name of the deceased worker.

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

Check the “Verified” block if we used the DOB to award U.S. benefits, or if the master beneficiary record (MBR) has a proof code for the DOB.

n. Worker/Contributor’s date of death

Enter the deceased worker’s date of death in survivor claims.

Check the “Verified” block if SSA used the date of death to award U.S. benefits, or if the MBR has a proof code for the date of death.

o. Date of marriage

Enter the date of marriage if a spouse or widow(er) is claiming benefits. Check “Verified” if we used the date of marriage to award U.S. benefits or if the MBR has a proof code for the date of marriage.

p. Date of divorce

Enter the date of divorce if a divorced spouse or widow(er) is claiming benefits. Check “Verified” if we used the date of divorce to award U.S. benefits or if the MBR has a proof code for the date of the divorce.

q. Country of birth

Enter the country of birth for the worker. Check “Verified” if we used the data to award U.S. benefits or if the MBR has a proof code for the country of birth.

r. Worker’s citizenship

Enter the country of citizenship of the worker. Check “Verified” if we used the data to award U.S. benefits or if the MBR has a proof code for the worker’s citizenship.

2. Providing information to Icelandic Liaison Agency

If you send an initial claims package or respond to an assistance request, check all appropriate blocks to indicate the type of material you sent to the Icelandic Liaison Agency.

a. Coverage record

Check this block when including a U.S. earnings record.

b. Icelandic applications

Check this block when including Icelandic applications.

c. Medical evidence

Check this block when including medical evidence the claimant submitted or from SSA files.

d. Date information requested

Indicate the date of the Icelandic Liaison Agency’s request if responding to a request from them.

e. Other

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

3. Information SSA needs from the Icelandic Liaison Agency

If you are requesting information under the Agreement, check “Yes.”

If you answer “No,” attach a consent statement.

Check at least one block to indicate the type of material we are requesting from the Liaison Agency:

a. Icelandic coverage record

Check this block to request the Icelandic certified coverage record.

b. Medical evidence

Check this block to request medical evidence from the Icelandic Liaison Agency.

c. Status of request date

Check this block to follow up on an earlier request to the Icelandic Liaison Agency. Show the date of the original request in the space provided.

d. Other

If requesting information not covered by items in GN 01772.220B.3.a. through GN 01772.220B.3.c., briefly explain the request in the space provided for in “Remarks.”

4. Remarks

Add only necessary remarks and make them clear and concise. Do not use technical jargon or abbreviations. Be sure to enter your name in the signature block.

 

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0201772220
GN 01772.220 - Completing the Form SSA e2960 USA/IS3 (U.S. – Iceland Agreement on Social Security Transmittal/Request/Certification) - 10/19/2023
Batch run: 10/19/2023
Rev:10/19/2023