Effective Dates: 04/11/2013 - Present Previous | Next

TN 1 (04-13)

GN 01752.220 Completing the SSA-2960 USA/PO3 (U.S.A. – Poland Agreement on Social Security Transmittal/Request/Certification Form)

A. Process for the SSA-2960 USA/PO3

The Office of International Operations (OIO), and the Warsaw, Poland Federal Benefits Unit (FBU) completes the SSA-2960 USA/PO3 via the Totalization Data Collection Program (TDCP). Use the SSA-2960 USA/PO3 to:

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    Transmit claims and related material to ZUS or KRUS;

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    Request information from ZUS or KRUS; and

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    Respond to requests from ZUS or KRUS.

Poland provides a wide range of benefits including retirement, survivors and disability benefits; one-time indemnity payments and benefits awarded as a result of work accidents and occupational diseases, and funeral grants through two major Social Security systems.

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    The Social Insurance Institution (Zaklad Ubezpieczen Spolecznych-ZUS) is a two-tier system that administers the social security provisions under the old and new laws in Poland for non-agricultural workers, and

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    The Agricultural Social Insurance Fund (Kasa Rolniczego Ubezpieczenia Spolecznego-KRUS) administers the social security provisions under the laws governing farmers in Poland.

B. Procedure for completing the SSA-2960 USA/PO3 eform

Use the procedure in the following chart to complete the items on the SSA-2960 USA/PO3 eform.

Date of Original field

 

Date(s) of Follow-ups field

 

To field

 

From field

Date is automatically entered

 

Follow-up date(s) will automatically propagate.

 

Select the appropriate foreign agency

 

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

1. Completing Information about the claim on the SSA-2960 USA/PO3

Complete the following information about the claim on the SSA-2960 USA/PO3:

a. Name of Worker

Enter the first and last names of the worker.

b. Worker’s Full Name at Birth

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    Enter the maiden name, if the worker is a married woman.

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    Enter the name at birth for a man, if it is different.

c. Worker’s Sex

Enter the sex of the worker.

d. Worker’s Polish I.D. Number

If the number is on the application or on the ZUS/KRUS liaison form, enter the Polish I.D. Number.

e. U.S. Social Security Number

Enter the worker’s U.S. Social Security Number (SSN).

f. Claimant’s Name

Enter the claimant’s name at birth or maiden name, if the claimant is not the worker entered in item GN 01752.220B.1.a in this section.

NOTE: For “f1 Claimant’s Sex” enter the sex of the claimant.

g. Claimant’s Name at Birth

Enter the claimant’s name at birth.

h. Claimant’s Polish ID Number

Enter the Polish I.D. number, if available.

i. Claimant’s Reference Number

Enter the Polish Reference number.

j. Claimant’s U.S. SSN

Enter the claimant’s U.S. SSN.

k. Claimant’s Address and Telephone Number

Enter the claimant’s address and telephone number.

l. Type of Benefits

Enter the type of benefits claimed (U.S. or Poland) in the block provided for:

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    Retirement or Old Age

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    Disability

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    Survivors

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    Death Grant

m. Date Claims Filed

Enter the Date Claim Filed (Month/Day/Year).

2. Certification of Data

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.

a. Date of Birth/Name

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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.

c. Date of Marriage

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.

d. Date of Divorce

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.

e. Country of Birth

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.

f. Citizenship

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.

3. Providing information to the Polish agencies

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

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    Coverage Record

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

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    Republic of Poland Applications

    Check this block when including a Republic of Poland application.

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    Medical Evidence

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

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    Date Information Requested

    Indicate the date of ZUS or KRUS request if responding to a request from them.

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    Other

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

4. Information SSA needs from the Polish agencies

If you request 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 SSA is requesting from the Polish Agencies.

a. Polish Coverage Record

Check this block to request the Polish coverage record.

b. Medical Evidence

Check this block to request a copy of medical evidence from the ZUS or KRUS files.

c. Status of Request Dated

Check this block to follow up on an earlier request to ZUS or KRUS. Show the date of the original request in the space provided.

d. Other

Check this block to request information not covered in GN 01752.220B.4 in this section. Briefly explain your request in the Remarks box.      

5. Remarks portion of the SSA-2960 USA/PO3

Keep remarks to a minimum 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/0201752220
GN 01752.220 - Completing the SSA-2960 USA/PO3 (U.S.A. – Poland Agreement on Social Security Transmittal/Request/Certification Form) - 04/11/2013
Batch run: 04/11/2013
Rev:04/11/2013