Complete the Certification of Data part of the SSA-2960 USA/PO3 only when transmitting
a claim for Polish benefits, for specific information in response to ZUS or KRUS.
If the requested information is not available, indicate “unknown.” If you know the
requested information, but our records cannot verify the information, enter the information,
and do not check the “Verified” block.
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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.
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Enter the date of birth for all claimants and, if applicable, for the deceased worker.
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Enter the relationship for all claimants and, if applicable, for the deceased worker.
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Enter the date the claimant provided the information (month/day/year).
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If we use the date of birth to award U.S. benefits, or the date indicated on the master
beneficiary record (MBR) as proof, check the “Verified” block.
b. Worker/Contributor’s Insured Date of Death
Enter the deceased worker’s date of death in survivor claims. Check the “Verified”
block if we used the date of death to award U.S. benefits, or the MBR has a proof
code for the date of death.
Enter the date of marriage if a spouse or widow(er) claims benefits. Check the “Verified”
block if we used the date of marriage to award U.S. benefits or the MBR has a proof
code for the date of marriage.
Enter the date of divorce if a divorced spouse or widow(er) claims benefits. Check
the “Verified” block if we used the date of divorce to award U.S. benefits or the
MBR has a proof code for the date of the divorce.
Enter the country of birth for the worker. Check the “Verified” block if we used the
data to award U.S. benefits or the MBR has a proof code for the country of birth.
Enter the country of citizenship of the worker. Check the “Verified” block if we used
the data to award U.S. benefits or the MBR has a proof code for the worker’s citizenship.