TN 2 (09-85)

GN 01704.718 Transmittal/Request/Certification Form (SSA-2960-U3-GE)

A. Description

  1. This is a 3-page snapout form.

    1. Page 1 is blue and printed in English. It is completed and filed in the folder as documentation.

    2. Page 2 is white and printed in German. The copy is initially sent to the appropriate German agency.

    3. Page 3 is yellow and printed in German. If necessary it is used as a followup request.

  2. The information and verification entered on page 1 corresponds to the information that is forwarded to Germany on pages 2 and 3.

B. Purpose

This Transmittal/Request/Liaison Form is used to:

  1. Transmit material and information to Germany; and

  2. Request material and information from Germany; and

  3. Verify data to the German agency.

C. Completion

1. General

  1. COMPLETE THIS FORM IN LEGIBLE BLOCK PRINTING. Use a ball point pen to ensure that the forms sent to the German agency are clear and dark enough to be easily read.

  2. Enter dates in MM/DD/YY or MM/YY format.

  3. Enter current date in upper-right corner.

  4. Enter name and address of appropriate German agency in “To” block.

2. Part I.—Information about the claim

  1. Always complete items A., B. and C. If the German insurance number (GIN) is not known, enter “UNKNOWN” in item C. and complete II.A.1., 2., and 3.

  2. Complete items D. and E., if you are transmitting an application for a German pension.

  3. Complete item F. if you are transmitting an application for a German pension, completed by a person other than the worker.

3. Part II—Certification of data

  1. Complete Part II if:

    1. You are transmitting a claim for German benefits; or

    2. You are requesting information about a worker whose GIN is unknown, in which case complete items A.1., A.2., A.3. and A.4.; or

    3. A German agency has requested specific data or a Form USA/D4.

  2. Check “Verified” if:

    1. The data has been used to award U.S. benefits; or

    2. The data is shown on the MBR as proven (see GN 01704.550); or

    3. The data block is “Citizenship, Stateless Refugee”—in which case see GN 01704.520.

  3. Most items are self-explanatory, complete as appropriate. However, when completing item “A.5, Periods of Disability”, check the “No” block if there is not now or never has been a period of disability; check the “Yes” block and show beginning and ending dates of disability, if there has been such a period.

4. Part III—Transmittal of information by U.S.

Check the appropriate block(s) and complete fill-ins, if applicable.

5. Part IV—Request for information from FRG

  1. Check the appropriate block(s) and complete fill-ins, if applicable.

  2. When requesting a German earnings record, enter either “01/37 on” or “01/51 on.” A CA should have documented the folder with the correct data. Check with the CA or a CATA if this documentation is missing.

6. Part V—Remarks

  1. Enter any additional information, clarification or explanation in this block. Entries should be complete enough to be comprehensible but not wordy. Do not use jargon.

  2. Sign your name.

  3. Affix OIO stamp.

D. Followups and requests for status

  1. Identify all followups by printing “URGENT” in red across the top of page 3, the yellow followup copy.

  2. If page 3 is not clear, make reentries using page 1 as a guide. If page 3 cannot be made legible, complete the yellow copy of a fresh form.

    NOTE: All followups or status requests must be yellow.

  3. If additional followups become necessary, use the yellow page of a fresh form. Enter the dates of all previous requests, using “Remarks” section, if necessary. Always print “URGENT” across the top of the form.

E. Diary period

  1. Diary initial requests to German agencies for: