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Date of Original
(M/D/Y)
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Current date automatically propagates.
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Date(s) of Follow-Up(s)
(M/D/Y)
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Follow-Up dates automatically propagate.
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From:
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Office / Office Code and Fax numbers automatically generate based on User’s profile.
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To:
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Check the appropriate block.
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1. Information About The Claim
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a. Name of Number Holder (NH)
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Enter number holder’s name.
If the NH is deceased, enter “Deceased” after the name.
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b. Name at Birth
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Enter name at birth.
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c. Canadian Social Insurance Number or Old Age Security Number
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Enter the Canadian number or Old Age Security Number.
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d. U.S. Social Security Number (SSN)
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Enter the U.S. SSN.
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e. Father’s Name
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Enter the father’s first name and last name.
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f. Mother’s Maiden Name
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Enter the mother’s first name, married last name, and in the third box, enter the
maiden name.
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g. Address of Number Holder/Claimant
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Enter number holder’s or claimant’s address.
If the NH is deceased, change the block label to “Address of Claimant” and enter the
name and address of the claimant here.
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h. Telephone Number
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Always enter the claimant’s telephone number, if known.
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i. Type of Benefits Claimed
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Check the appropriate benefits under the appropriate country.
Do not complete when responding to assistance requests.
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j. Date Claim Filed
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Protective Filing Date for the claim.
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2. Certification of Data
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Enter the date of birth in the appropriate fields if applicable.
Enter the first and last name in the appropriate fields if applicable.
Check the verified column for all information verified.
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a. Date of Birth
Number Holder
Spouse/Widow(er)
Child
Child
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b. Number Holder’s Date of Death
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Enter the number holder’s date of death, and check the verified field to confirm verification
of information if applicable.
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c. Date of Marriage
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Enter the number holder’s date of marriage, and check the verified field to confirm
verification of information if applicable.
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d. Date of Divorce
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Enter the number holder’s date of divorce, and check the verified field to confirm
verification of information if applicable.
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3. Information Provided
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Check the appropriate information the claimant provided below.
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a. Application
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b. Evidence of Coverage Periods
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c. Medical Evidence
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d. Residence Documents
Note: Quebec 2960 does not have d. Residence Documents
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e. Request for Appeal
(Please note that this numbering (e. – g.) does not reflect the numbering on SSA-e2960-QC.
)
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f. Information Requested On
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Enter the name of the person the information is being provided for (if appropriate)
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g. Other
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Complete this field for other information provided that is not already listed.
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4. Information Required
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Check the appropriate information we are requesting below. Do not complete item b.
when requesting information from Ottawa. We have agreed not to routinely request medical
evidence from Ottawa.
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a. Evidence of Coverage Periods
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b. Medical Evidence
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c. Status of Request Date
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d. Other
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Complete this field for other information we require that is not on the form.
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e. No Information Required
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Place a check mark in this field if no information is required or /requested.
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Remarks
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Keep remarks to a minimum. When needed, remarks should be clear and concise. Do not
use technical jargon or abbreviations.
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Enter the year the worker last worked in Canada, if known.
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Signature
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Your name will propagate in this field along with the current date and the Social
Security emblem.
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