TN 2 (02-95)

GN 01712.220 Completing the USA/Norway Transmittal/Request/Certification Form (SSA-2960-U2-NE)

A. When to use

Totalization technicians in DIO and FSP personnel in the American Embassy in Oslo communicate with the FFU via Form SSA-2960-U2-NE. FFU personnel use a similar form to communicate with SSA. Form SSA- 2960-U2-NE is used to:

  • transmit claims and related material to the FFU.

  • request information from the FFU, and

  • send information requested by the FFU.

B. Description of the SSA-2960-U2-NE

The SSA-2960-U2-NE is a two page, bilingual form printed in English and Norwegian:

  • The top page is sent to the FFU.

  • The second page is used as folder documentation or to follow-up on a request to the FFU.

C. Procedure

Follow this table to complete the items on the form. MAKE ALL ENTRIES IN LEGIBLE BLOCK PRINTING WITH A BALL POINT PEN.

 

Item of FormTake This Action
  1. Information
    About the
    Claim

Complete the items in Part I as follows:

  • Item A - Always enter the first, middle and last names of the worker.

  • Item B - Always enter the worker's U.S. SSN. If you don't know the SSN, enter “UNKNOWN.”

  • Item C - Always enter the worker's Norwegian Personal Number (PIN). If you don't know the PIN, enter “UNKNOWN” in C. and complete Part II A. Also include in Part VI the place of birth, last address in Norway, and date of last residence in Norway.

NOTE: If claimant last lived in Norway before January 1967, he/she will not have a PIN because the Norwegian insurance system began on January 1, 1967.

 
  • Item D - Complete the name and address block to inform the FFU about a claim for Norwegian benefits and in response to a Norwegian agency's request for address information.

  • Item E - On initial claims packages indicate the type of claim for Norwegian benefits.

  • Item F - Enter the filing date being certified to the Norwegian agency on all initial claims packages and in response to a Norwegian agency's request for the filing date.

  1. Certification of Data

  • Complete the appropriate section(s) to inform the FFU about claimants for Norwegian benefits.

  • "X” the verified block(s) if the data has been used by SSA to adjudicate claims.

III. Certification
of Benefit
Data

Complete this section to respond to a request for benefit information from the FFU. Be aware that the FFU should request this information only for widows or workers entitled to survivors or disability benefits from both the U.S. and Norway. Complete by entering:

  • First and last name of beneficiary.

  • Type of benefit applied for: e.g., widow.

  • Determination made on the claim; i.e., either “awarded” or “denied.”

  • First month and year of entitlement, if the claim was awarded, in MM /YY format.

  • Current MBA. If terminated, show “terminated.”

  • Month and year of termination, if appropriate, in MM/YY format.

IV.

Material
Attached

"X” the appropriate block(s) when transmitting information or material to the FFU.

  1. Information
    Requested

"X” the appropriate block(s) to request information or material from the FFU.

VI.

Remarks

Enter clarifying or additional information. Be concise and do not use jargon.

Signature/Date

Sign and date the form, but do not affix the