TN 1 (12-93)
GN 01732.220 Completing the U.S./Finland Agreement on Social Security Transmittal/ Request/Certification Form (SSA-2960-U3-FI)
A. When to use
The SSA-2960-U3-FI is completed in the totalization modules in OIO and by the RFSP in Stockholm. It is used to:
transmit claims and related material to the CPSI or the SII;
request information from the CPSI; and
respond to requests from the Finnish agencies.
NOTE: Blocks for verifying dates and certifying monthly benefits are completed only by OIO.
B. Description of form SSA-2960-U3-FI
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 Finnish and is the initial copy sent to the Finnish agency.
Page 3 (Yellow follow-up copy) is written in Finnish and is used as a follow-up request when necessary.
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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|
|TO:||Note that this block is pre-printed with the address of the CPSI. When mailing to the SII, place the SII label over the preprinted CPSI address.|
|FROM:||Check the appropriate block.|
|I. 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.
Item C - always enter the worker's Finnish Population Register Number if it is shown on the application or on the Finnish liaison form.
Item D - on initial claims packages indicate the type of claim for Finnish and/or U.S. benefits.
Item E - enter the filing date being certified to the Finnish agency on all initial claims packages and in response to a Finnish agency's request for the filing date.
Item F - complete the name and address block in all initial claims packages and in response to a Finnish agency's request for address information.
|II. Certification of Data - Item A||Complete the Certification of Data part of the form when transmitting a claim for Finnish benefits or when replying to a Finnish 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 last names and, if applicable, the maiden name.
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.
Entitled Since and Monthly Amount (Completed only by OIO) - Complete these blocks when benefits have been awarded if a claim for Finnish benefits is or has been transmitted; OR a Finnish agency has requested the information and a signed authorization is in file.
For retirement or disability claims, enter the MBA for the worker and spouse effective with the first month of entitlement or November 1992, whichever is later.
For survivor claims, enter the MBA for the deceased worker effective with the month prior to the month of death. Enter the MBA for the widow and surviving children effective with the first month of entitlement for survivor benefits or November 1, 1992, whichever is later.
NOTE: Benefit amounts shown should be the amount before reduction for nonresident alien tax, SMI premiums, etc.
II. Certification of Data - Item B