Complete the following information about the claim on the Form SSA 2960 USA/BR 3:
a. Name of worker
Enter the first and last name(s) of the worker.
b. Name of worker at birth
Enter the maiden name if the worker is a married woman; and enter the name at birth
for a man, if it is different.
c. Worker's sex
Check the appropriate sex of the worker.
d. Brazilian birth registration number
Enter the Brazilian birth registration number, if the number appears on the application
or on the Brazilian liaison form. If the claimant did not provide the Brazilian birth
registration number, indicate UNKNOWN in the Remarks field and provide the following
information about the claimant.
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
Enter the maiden name if the claimant is a married woman; and enter the name at birth
for a man, if it is different.
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 and Brazilian
benefits, both, in the appropriate columns.
k. Date
claim
filed
Enter the filing date certified to the Brazilian liaison agency on all initial claims
packages or in response of the agency’s request for the filing date.
Certification of data
Complete the certification of data part of the form only when transmitting a claim
for Brazilian benefits in response to INSS’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.
l. Name and date of birth
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 for the deceased worker.
Check the “Verified” block if SSA used the DOB to award U.S. benefits, or the master
beneficiary record (MBR) has a proof code for the DOB.
m. 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 the MBR has a proof
code for the date of death.
n. Date of
marriage
Enter the date of marriage if a spouse or widow(er) is claiming benefits. Check the
“Verified” block if SSA used the date of marriage to award U.S. benefits or the MBR
has a proof code for the date of the marriage.
o. Date of
divorce
Enter the date of divorce if a divorced spouse or widow(er) is claiming benefits.
Check the “Verified” block if SSA used the date of marriage to award U.S. benefits
or the MBR has a proof code for the date of the divorce.
p. Country of birth
Enter the country of birth for the worker. Check the “Verified” block if SSA used
the data to award U.S. benefits or the MBR has a proof code for the country of birth.
q. Worker's citizenship
Enter the country of citizenship of the worker. Check the “Verified” block if SSA
used the data to award U.S. benefits or the MBR has a proof code for the worker’s
citizenship.