TN 2 (09-85)
GN 01704.716 Transmittal/Request/Certification Forms (SSA-e2960)
The Transmittal/Request/Certification form is the cover sheet of packages and requests prepared for foreign agencies in Norway and Belgium. As the name suggests, it is a multipurpose form used to transmit information and material to foreign agencies, to request information and material from foreign agencies and to certify information as verified when that information has been used to adjudicate a claim for benefits from the United States.
It is a two-page form consisting of the original (blue) and a file copy (white). The top section of the forms displays the foreign agency names and addresses on the left and DIO's totalization address on the right.
B. Completing the forms
COMPLETE THE FORMS IN LEGIBLE BLOCK PRINTING
1. Information about the claim (PART I)
If requesting foreign coverage information only, enter the name of the NH, the U.S. SSN of the NH and the number assigned to the NH by the foreign system. No additional entries are needed.
If informing the foreign agency about claims filed in the United States or a third country, complete all the blocks in this part.
Note: If the foreign number is unknown, enter “unknown” and complete part II.A.
2. Certification of data (PART II)
Check the verified blocks if the data have been used as a factor of entitlement to adjudicate claims for benefits from the United States.
Complete A. if a claim has been filed in the United States or a third country for benefits from Norway or Belgium. Do not complete “Date of Death” if the NH is alive.
Complete B. if a claim has been filed in the United States or a third country for spouse's or widow(er)'s benefits from Norway or Belgium. Do not complete “Date of Divorce” if the spouse is not divorced from the NH.
Complete C. if a claim has been filed in the United States or a third country for child(ren)'s benefits from Norway or Belgium.
3. Certification of benefit data (PART III)
Complete with U.S. benefit data only when the foreign agency requests it.
4. Material attached (PART IV)
Check the block(s) which apply to the material being transmitted to the agency. If “E. Other” is checked, specify the type of material.
5. Information requested (PART V)
Check the block(s) which apply to the information requested from the agency. If “E. Other” is checked, specify the material needed in “Part VI. Remarks.”
6. Remarks (PART VI)
Enter explanatory or additional information.
7. Sign and date the form
Do not authenticate.
The Form SSA-e2960-U2-NE is a bilingual form printed in English and Norwegian. It is similar to but not identical to the form the FFU uses to communicate with DIO.
Certification of Benefit Data, Part III, should be completed only if the FFU specifically requests it and only for the beneficiaries named in the FFU request. Part III is completed as follows:
Enter first and last name of beneficiary.
Enter type of benefit applied for: e.g., “disabled widow.”
Enter the determination made on the claim; i.e., either “awarded” or “denied.”
Enter the first month and year of entitlement, if the claim was awarded.
Enter the current monthly benefit amount credited. If terminated, show “terminated.”
Enter month and year of termination if appropriate.
The Form SSA-e2960-U2-BE is printed in English only. It is identical in format to the foreign language form the Belgian agencies use to communicate with DIO.
Complete those items which are special to the SSA-e2960-U2-BE as follows:
1. Address of the Belgian agency
Information or requests concerning retirement or survivor claims should be sent to the Rijksdienst voor Werknemerspensioenen (pensions institute). Information or requests concerning disability claims should be sent to the Rijksinstituut voor Ziekte-en Invaliditeitsverzekering (invalidity institute). If both retirement and disability claims have been filed, send the material to the pension institute. Designate the correct address by crossing out the address that is not used. This item must be completed in all cases.
2. Part I—Information about the claim
Items A through E are self-explanatory.
Item F—Date Benefit Elected/Date Work Ceased
These blocks are completed when a claim for Belgian retirement benefits has been filed. The information can be obtained from item 8 on the SSA-799-F4.
Item G—Name and Address of Belgian Sickness Fund
This block is compl