TN 1 (06-12)
GN 01734.220 Completing the Form SSA-2960-LX (U.S. - Luxembourg Agreement on Social Security Transmittal/Request/Certification)
A. Process for using the Form SSA-2960-LX
The Office of International Operations (OIO) and the London, England, Federal Benefits Unit (FBU) completes the SSA-2960-LX via the Totalization Data Collection Program (TDCP).
Use the SSA-2960-LX to communicate with the Luxembourg agencies in the following instances:
transmit claims and related material to them;
request information from them; and
respond to requests from them.
B. Procedure for completing the Form SSA-2960-LX
Follow the procedure below to complete the items on the SSA-2960-LX electronic form.
Item on Form SSA- 2960-LX
Date of Original field
Date automatically propagates
Date(s) of Follow-ups field
Follow-up date(s) automatically propagates
Select the appropriate foreign agency
Office/Office Code and Fax numbers automatically generate based on User’s profile.
Information About the Claim
Enter the following information in Part 1, a. through g., of the SSA-2960-LX as follows:
Name of Worker
Enter the first and last name of the worker.
Enter the first and last name at birth.
NOTE: Luxembourg must have this information to locate the worker's records.
U.S. Social Security Number
Enter the worker's U.S. SSN.
Luxembourg Registration Number
Enter the worker's Luxembourg Registration Number if it is on the application or on the Luxembourg liaison form.
If unknown, enter “unknown.”
Name of Claimant
Enter the claimant’s first and last name.
Enter the claimant’s first and last name at birth.
Show the claimant's maiden name.
NOTE: Luxembourg needs this information to assign a registration number.
Address of Claimant
Enter the claimant’s address and telephone number in the appropriate boxes.
Type of Benefits Claimed
Select the column with the type of benefits claimed. In initial claims packages, indicate the type of claim for Luxembourg or U.S. benefits.
Date Claim Filed (M/D/Y)
Enter the certified filing date to the Luxembourg agency on all initial claims packages and in response to a Luxembourg agency's request for the filing date.
Certification of Data
Enter the following information in Part 2 of the SSA-2960-LX in all cases:
Date of Birth
Enter the first and last names of all claimants.
Enter the date of birth for all claimants.
Check the appropriate block if OIO used the date of birth to award U.S. benefits; or SSA proved the data shown on the Master Beneficiary Record (MBR).
Enter the following information in Part 2 if SSA is transmitting a claim for Luxembourg benefits, or if a Luxembourg agency requested the information.
Enter the amount of the monthly benefit creditable (MBC) for the first month in which a full benefit was paid or November 1, 1993, whichever is later.
For retirement and disability claims, enter the MBC for the worker. For survivor claims, enter the MBC for the widow and children.
Effective Date (M/Y)
Enter the first month and year that SSA paid a full benefit, or November 1, 1993, whichever is later.
If the claim is for survivor benefits, enter the effective date of the survivor benefits.
Worker’s Date of Death
Enter the date of death if applicable.
Date of Marriage
Enter the date of marriage if applicable.
Date of Divorce
Enter the date of divorce if applicable.
Check the appropriate blocks if OIO used the data to award U.S. benefits, or SSA proved the data shown on the MBR.
Prior Periods of Disability
Enter the following dates only if Luxembourg specifically requests this information.
If the worker was entitled to U.S. DIB benefits enter the beginning and ending date of entitlement. If the worker was not entitled to U.S. DIB benefits, enter “NONE”.
Check this block to certify DIB information.
Check the appropriate block(s) in a. through e. to indicate the type of material OIO sends to the Luxembourg agency.
if attaching a U.S. coverage record
if attaching medical evidence submitted by the claimant or from OIO files
Information Requested On (M/D/Y)
if responding to a request from a Luxembourg agency and enter the date of the request
No Information Provided
if there are no attachments
Other – See Remarks
if attaching material not covered by any block shown above
NOTE: Briefly explain the attachment in “REMARKS.”
Check the appropriate block(s) in a. through e. to indicate the type of material OIO requests from the Luxembourg agency.
if requesting a Luxembourg coverage record
if requesting a copy of medical evidence from the Luxembourg agency's files
Status of Earlier Request (M/D/Y)
if following up on an earlier request to the Luxembourg agency and show the date of the original request
No Information Provided
if you are not requesting any information
Other – See Remarks
if you are requesting information not covered by a block shown above
NOTE: Briefly explain your request in “Remarks.”
Keep remarks to a minimum and make them clear and concise. Do not use technical jargon or abbreviations.
C. Exhibit of the Form SSA-2960-LX
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