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