GN 01722.220 Completing the U.S./Spain Agreement on Social Security Transmittal/ Request/Certification Form (SSA-2960-U3-SP)
A. When to use
The SSA-2960-U3-SP is completed in the totalization modules in OIO and by the FSP in Madrid. It is used to:
transmit claims and related material to the Spanish agencies;
request information from the Spanish agencies; and
respond to requests from the Spanish agencies.
NOTE: Blocks for verifying dates and certifying monthly benefits are completed only by OIO.
B. Description of form SSA-2960-U3-SP
The form consists of three pages.
Page 1 (Blue file copy) is written in English and is used for folder documentation.
Page 2 (White First Request Copy) is written in Spanish and is the initial copy sent to the Spanish agency.
Page 3 (Yellow follow-up copy) is written in Spanish and is used as a follow-up request when necessary.
Follow this table to complete the items on the form. MAKE ALL ENTRIES IN LEGIBLE BLOCK PRINTING WITH A BALLPOINT PEN.
|ITEM ON FORM||TAKE THIS ACTION|
|Ref. No.||Enter the reference number shown on the most recent liaison form from the Spanish agency. If there is no liaison form in file, leave the item blank.|
|TO:||Affix the mailing label for the correct Spanish agency. (See GN 01722.040 - GN 01722.045 for instructions for determining the correct Spanish agency).|
|FROM:||Check the appropriate block.|
| || |
I. GENERAL INFORMATION
Complete the items in Part I as follows:
Item A - always enter the first, middle and both surnames of the worker
Item B - always enter the worker's U.S. SSN
Item C - always enter the worker's Spanish Social Insurance Number if it is shown on the application or on the Spanish liaison form. If unknown, enter “unknown.”
Item D - enter the filing date being certified to the Spanish agency on all initial claims packages and in response to a Spanish agency's request for the filing date.
Item E - on initial claims packages indicate the type of claim for Spanish and/or U.S. benefits.
Item F - complete the name and address block in all initial claims packages and in response to a Spanish agency's request for address information.
CERTIFICATION OF DATA-ITEM A
Complete the Certification of Data part of the form when transmitting a claim for Spanish benefits or when replying to a Spanish agency's request for specific information.
Name - Always enter the names of all claimants and in survivor cases, the name of the deceased worker. Enter the first name, middle and surnames as shown on the Spanish application form or in the Spanish agency's request for information.
Date of Birth - Enter the date of birth for all claimants and for the deceased worker.
Verified - (Completed only by OIO) check this block if the date of birth has been used to award U.S. benefits; OR the date of birth is shown on the MBR as proven.
Date of death, marriage and divorce - Complete these items only if transmitting a claim for Spanish benefits, OR responding to a Spanish agency request.
Verified - (Completed only by OIO) Check this block if the data has been used to award U.S. benefits, OR the data is shown on the MBR as proven.
CERTIFICATION OF DATA -ITEM B
OIO completes this part of the form if a claim for Spanish benefits is being transmitted; or a Spanish agency has requested the information.
For retirement or disability claims, complete this section for the worker.
For survivor claims, complete this section for the widow and children.
Complete the items as follows:
Pending, Denied, Awarded - check the appropriate block.
Type of Benefit - Enter retirement, survivor or disability.
Amount - Enter the amount of the monthly benefit creditable (MBC) for the first month in which a full benefit was paid or April 1, 1988, whichever is later.
Effective Date - Enter the first month and year in which a full benefit was paid or April 1, 1988, whichever is later.
NOTE: If the claim is for survivor benefits, enter the effective date of the survivor benefits.
Check the block(s) to indicate the type of material being sent to the Spanish agency. Check item:
if attaching a Spanish application form E/USA
if attaching a U.S. coverage record
if attaching medical evidence submitted by the claimant or from OIO files
if attaching form E/USA 2 (Statement of Working Life).
if attaching the worker's Spanish Navigation Book.
if responding to a request from a Spanish agency and enter the date of the request.
if attaching material not covered by any block shown above and briefly explain the attachment in “REMARKS.”
Check the block(s) to indicate the type of material being requested from the Spanish agency. Check item:
if requesting a Spanish coverage record.
if requesting a copy of medical evidence from the Spanish agency's files.
if following up on an earlier request to the Spanish agency and show the date of the original request.
if you are not requesting any information.
If you are requesting information not covered by a block shown above. Briefly explain your request in “Remarks.”
Keep remarks to a minimum and make them clear and concise. Do not use technical jargon or abbreviations. Be sure to sign, date and apply the OIO stamp.
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