TN 4 (03-12)
GN 01710.220 Completing the SSA-e2960-SZ (U.S.-Swiss Agreement Transmittal/Request/Certification Form)
A. Process for the SSA-e2960-SZ
The Division of International Operations (DIO), and the Frankfurt, Germany Federal Benefits Unit (FBU) completes the SSA-e2960 –SZ via the Totalization Data Collection Program (TDCP). Use the SSA e2960-SZ to:
transmit claims and related material to the Swiss agency,
request information from the Swiss agency, and
respond to assistance requests from the Swiss agency.
B. Exhibit of the SSA-e2960-SZ
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C. Procedure for completing the eform SSA-e2960 SZ
Follow the procedure below to complete the items on the eform.
Date of Original field
Date(s) of Follow-ups 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-e2960-SZ
Complete the following information about the claim on the SSA-e2960-SZ:
a. Name of worker
Enter the first and last names of the worker
b. Full name at birth
Enter the worker's full name at birth
c. U.S. Social Security Number
Enter the worker’s U.S. Social Security Number
d. Swiss Insurance Number
Enter the worker’s eleven digit Swiss Insurance Number as shown on the application form or on the Swiss liaison form. Enter “unknown” if the Swiss Insurance Number does not exist.
e. Father’s name
Enter the father’s name
f. Mother’s maiden name
Enter the mother’s maiden name
g. Name of claimant
Enter the claimant’s name
h. Address of claimant
Enter the address of the claimant in all initial claims packages or in response to the Swiss agency’s request for address information.
i. Telephone Number
Enter the telephone number
j. Type of benefits claimed
Select the type of benefits claimed in initial claims packages.
k. Date claim filed
Enter the certified filing date to the Swiss agency in all initial claims packages or in response to the Swiss agency’s request for the filing date.
2. Certification of Data portion of the SSA-e2960-SZ
Complete the Certification of Data part of the form only when transmitting a claim for Swiss benefits or when replying to the Swiss agency's request for specific information.
Enter the first and last names of all claimants. In survivor cases, enter the first and last e name of the deceased worker.
Enter the dates of birth, citizenship and relationship for all claimants listed.
b. Worker’s date of death
Enter the worker's date of death if appropriate and relevant to the claim.
Enter the date of marriage if appropriate and relevant to the claim.
Enter date of divorce if appropriate and relevant to the claim.
Select the “verified” blocks whenever we prove the data to SSA's satisfaction; i.e., SSA used the data to award U.S. benefits or the data is on the MBR as proven.
e. U.S. coverage
Complete item “e” on initial claims for
Swiss disability benefits or
orphans benefits on the record of a deceased mother or
when the Swiss agency requests U.S. coverage information.
Use item e. in lieu of sending an earnings record in Swiss agreement cases.
For disability cases, enter the year of filing. For orphan cases, enter the year of death on the bottom line of the “year” block.
Enter the next four preceding years in the other “year” blocks in chronological order with the earliest year on the top line.
Indicate the existence of U.S. QCs by selecting the appropriate boxes for the calendar quarters. Leave the boxes blank for calendar quarters in which QCs do not exist.
Indicate total QCs or “None”, as appropriate, for each year in the “total” column.
3. Providing Information to the Swiss agency
Check at least one block to indicate the type of material we are sending to the Swiss agency.
Check this block when including medical evidence the claimant submitted or from SSA files;
Request for appeal
Check this block to request- an appeal
Check this block for material not specifically covered by the other blocks.
4. Information SSA needs from the Swiss agency
Check at least one block to indicate the type of material SSA is requesting from the Swiss Agency.
a. Coverage record
Check this block to request the Swiss coverage record.
b. Medical evidence
Check this block to request a copy of medical evidence from the Swiss agency's files. Indicate the person's name in the space provided.
c. Status of our request dated
Check this block to follow up on an earlier request to the Swiss agency. Show the date of the original request in the space provided.
d. Other (See Remarks)
Check this block to request information not covered above. Briefly explain your request.
5. Action on Swiss claim
Complete this part of the SSA-e2960-SZ on initial claims packages when there is a claim for Swiss benefits.
If the claimant is a Swiss national, select the first block and indicate the date on which you referred him or her to a Swiss diplomatic office.
If the claimant is a non-Swiss national who completed a special Swiss application, select the second block and attach the Swiss application form. To determine the need for an application and for information on special applications for Swiss benefits for persons residing outside Switzerland, see GN 01710.315.
6. Remarks portion of the SSA-e2960-SZ
Keep remarks to a minimum and make them clear and concise. Never use technical jargon or abbreviations. Include specific remarks in the following situations:
on claims for Swiss disability benefits or orphans, benefits on the record of a deceased mother indicate any periods of entitlement to U.S. benefits that the disabled person has or the deceased mother had on any SSN.
If the claimant is a third country national (not U.S. or Swiss) and SSA requested a Swiss coverage record, enter “Although the claimant is a third country national, he/she may be eligible for U.S. benefits by virtue of point 13 of the Final Protocol to the Agreement.”
if a refugee or stateless person residing in a third country or a third country national filed for Swiss benefits, enter “Third country national (or refugee or stateless person) filed for Swiss benefits. Your disposition necessary.” Note: This remark advises the Swiss agency that SSA is merely forwarding the information pertaining to this person (SSA understands that when applying the US/Swiss agreement no payment can be made to such person) to check whether the Swiss agency might be able to pay benefits without applying the US/Swiss agreement (non-TOT benefits from Switzerland).