GN 01736.220 Completing the U.S./Ireland Agreement on Social Security Transmittal/ Request/Certification Form (SSA-2960-U3-IR)
A. When to use
The SSA-2960-U3-IR is completed in the totalization modules in OIO and by the FSP in Dublin. It is used to:
transmit claims and related material to the Irish agency
request information from the Irish agency; and
respond to requests from the Irish agency.
Note: Blocks for verifying dates are completed only by OIO.
B. Description of form SSA-2960-U3-IR
The form consists of three pages.
Page 1 (Blue file copy) is used for folder documentation.
Page 2 (White First Request Copy) is the initial copy sent to the Irish agency.
Page 3 (Yellow follow-up copy) is used as a follow-up request when necessary.
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Follow the procedure below to complete the items on the form. MAKE ALL ENTRIES IN LEGIBLE BLOCK PRINTING WITH A BALLPOINT PEN and be sure to check OIO or FSP in the “FROM” block as appropriate.
1. GENERAL INFORMATION
Complete the items in Part I as follows:
Item A - always enter the first, middle and last names of the worker and if the worker is a married woman, her maiden name.
Item B - always enter the worker's U.S. SSN
Item C - always enter the 4 digit Ireland Social Insurance Number, if the worker worked in Ireland before 1979 and the number is shown on the application or on the Irish liaison form.
Item D - always enter the 8 or 9 digit Ireland Revenue and Social Insurance Number (7 numeric, 1 or 2 alpha) if the worker worked in Ireland after 1978 and the number is shown on the application or on the Irish liaison form.
NOTE: If, on an initial claims package, neither of the Irish Insurance numbers is available to enter in Items C and D above, refer to GN 01736.220.D.6 for entries in the remarks portion.
Item E - on initial claims packages indicate the type of claim for U.S. benefits and/or Irish benefits in the appropriate columns.
Item F - enter the filing date being certified to the Irish agency on all initial claims packages or in response to the Irish agency's request for the filing date.
Item G - complete the name and address block in all initial claims packages or in response to the Irish agency's request for address information.
2. CERTIFICATION OF DATA - ITEM A
Complete the Certification of Data part of the form only when transmitting a claim for Irish benefits or when replying to the Irish agency's request for specific information.
Name - 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.
3. CERTIFICATION OF DATA - ITEM B
Date of death, marriage and divorce - Complete these items only if transmitting a claim for Irish benefits, OR responding to a request from the Irish agency.
"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.
U.S. Period of Disability (completed by OIO only). Enter the month and year of the beginning and ending date of any established U.S. period of disability, whenever you are transmitting a claim for Irish disability benefits. If no period of disability has been established, check the “none established” box. GN 01736.315 explains how to determine the proper beginning and ending dates.
Check at least one block to indicate the type of material being sent to the Irish agency. Check item:
if attaching a U.S. coverage record.
if attaching medical evidence submitted by the claimant or from SSA files.
if responding to a request from the Irish agency and enter the date of the original request.
if no material is attached.
if attaching material not covered by any block shown above and briefly explain the attachment
Check at least one block to indicate the type of material being requested from the Irish agency. Check item:
if requesting an Irish coverage record.
if requesting a copy of medical evidence from the Irish agency's files.
if following up on an earlier request to the Irish 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.
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.
If neither of the worker's two Irish insurance numbers are known, and the field office listed the worker's prior home addresses in Ireland in the remarks section of the form SSA-2490-F4 (See GN 01735.215.D) enter “See attached list of home addresses in Ireland” in the remarks section. Attach a photocopy of the Remarks part of the SSA-2490-F4
In claims for Irish widow's benefits enter the widow's own Irish insurance number(s) as found in the remarks section of form SSA-2490-F4. Identify it as “widow's Irish insurance number”.
When sending a follow-up request, enter the date in the appropriate block of the yellow follow up copy as well as the blue file copy.