GN 01740.220 Completing the U.S. Liaison Form SSA-2960-CHI

A. When to use

The SSA-2960-CHI is completed by the totalization module in DIO or by the FSP in Buenos Aires. It is used to:

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Transmit claims and related material to a Chilean agency,
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Request information from a Chilean agency, and
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Respond to requests from a Chilean agency.

B. Description

This is an electronic form and can be located, completed and printed by accessing the Totalization Data Collection Program (TDCP).

C. Procedure

Follow these instructions to complete the items on the form. Be sure to check the appropriate address information in the “FROM” block.

1. Information about the claim

Complete the items in Part 1 as follows:

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Item a – always enter the name and both surnames of the worker.
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Item b – always enter the name at birth if the worker is a married woman. Enter the name at birth for a man, if it is different from the current name.
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Item c – always enter the worker's National Personal Identification Number or R.U.T. (See GN 01740.315 for a description of the R.U.T.)
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Item d – enter any other Social Insurance number for a worker who contributed to the old system.
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Item e – always enter the worker's U.S. SSN.
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Item f – enter the worker's father's name if the Chilean R.U.T. or Social Insurance Number is unknown.
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Item g – enter the worker's mother's name if the Chilean R.U.T. or Social Insurance Number is unknown.
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Item h – always enter the complete address of the claimant.
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Item i – always enter the claimant's telephone number.
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Item j – on initial claims packages, indicate the type of claim for U.S. benefits and/or Chilean benefits in the appropriate columns.
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Item k – enter the filing date being certified to the Chilean agency on all initial claims packages or in response to the Chilean agency's request for the filing date.

2. Certification of data

Complete the Certification of Data part of the form only when transmitting a claim for Chilean benefits or in response to a Chilean agency's request for specific information.

a. Item a – name and date of birth

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Enter the names of all claimants and in survivor cases, the name of the deceased worker. Enter the names and surnames, and, if different from current names, the names at birth.
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Enter the date of birth for all claimants and, if applicable, for the deceased worker.
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Check the “Verified” Block if the date of birth has been used to award U.S. benefits, OR the date is shown on the MBR as proven.

b. Item b – worker's date of death

Enter the deceased worker's date of death in survivor claims. Check “Verified” if the data has been used to award U.S. benefits, OR the date is shown on the MBR as proven.

c. Item c – date of marriage

Enter the date of marriage if a wife or widow is claiming benefits. Check “Verified” if the data has been used to award U.S. benefits, OR the date is shown on the MBR as proven.

d. Item d – date of divorce

Enter the date of divorce if a divorced wife or widow is claiming benefits. Check “Verified” if the data has been used to award U.S. benefits, OR the date is shown on the MBR as proven.

e. Status of U.S. claim

DIO completes this part of the form if a claim for Chilean benefits is being transmitted, or if a Chilean 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. Information about the amount and effective date of the benefit is only required for the widow.

Complete the items as follows:

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Pending, Denied, Awarded – check the appropriate block.
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Type of Benefit – enter “retirement, survivor or disability.
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Under the agreement – check “yes” if a totalization benefit is being paid; check “no” if a fully insured benefit is being paid.
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Amount – enter the amount of the monthly benefit creditable (MBC) for the month in which the SSA-2960-CHI is being completed.

NOTE: If the claimant is dually entitled on another Social Security record, enter only the benefit amount paid on the worker's own record for retirement and disability claims. For survivor claims, enter the total benefit amount that the widow receives.

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Effective Date – Enter the current month and year.

3. Information provided

If you are sending an initial claims package or responding to an assistance request, check all appropriate blocks to indicate the type of material being sent to the Chilean agencies. Check item:

a.

If attaching a U.S. coverage record.
b.

If attaching medical evidence submitted by the claimant or from SSA files.
c.

If responding to a request from a Chilean agency and show the date of the original request.
d.

If attaching material not covered by any block shown above. Briefly explain the attachment in the space provided for “Remarks.”

4. Information required

If information is being requested from a Chilean agency, check one or more blocks to indicate the type of material being requested. Check item:

a.

In the “yes” block to indicate that information is needed to process a claim under the agreement.
b.

If requesting a Chilean coverage record.
c.

If requesting a copy of medical evidence from the Chilean agency's files.
d.

If following up on an earlier request to a Chilean agency and show the date of the original request.
e.

If requesting information not covered by a block shown above. Briefly explain the request in the space provided for Remarks”.

5. Remarks

If you are sending an initial claims package to a Chilean agency, check the appropriate block to show that a Chilean application has been mailed to the applicant. Be sure to sign and date the form.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0201740220

GN 01740.220 - Completing the U.S. Liaison Form SSA-2960-CHI - 01/18/2017
Batch run: 01/18/2017
Rev:01/18/2017

Program Operations Manual System (POMS)