The SSA-2960-KOR is completed in the totalization module in OIO or by VARO in Manila.
It is used to:
Transmit claims and related material to the NPC
Request information from the NPC, and
Respond to requests from the NPC.
This is an electronic form and can be located, completed and printed by accessing
the Totalization Data Collection Program (TDCP).
Follow these instructions to complete the items on the form. Be sure to check the
appropriate address information in the “FROM” block.
Complete the items in Part 1 as follows:
Item a – always enter the first and last names of the worker.
Item b – always enter the maiden name if the worker is a married woman. Enter the
name at birth for a man, if it is different.
Item c – always enter the place of birth.
Item d – always enter the worker's U.S. SSN.
Item e – always enter the 13 digit Korean National Pension Number if the number is
shown on the application or on the Korean liaison form.
Item f – always enter the complete name and address of the claimant.
Item g – always enter the claimant's telephone number.
Item h – on initial claims packages, indicate the type of claim for U.S. benefits
and/or Korean benefits in the appropriate columns.
Item i – enter the filing date being certified to the NPC on all initial claims packages
or in response to the NPC's request for the filing date.
Complete the Certification of Data part of the form only when transmitting a claim
for Korean benefits or in response to the NPC's request for specific information.
Enter the names of all claimants and in survivor cases, the name of the deceased worker.
Enter the first and last names and, if applicable, the maiden name.
Enter the date of birth for all claimants and, if applicable, for the deceased worker.
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.
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.
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.
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.
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 NPC.
If attaching the KOR-USA 1.
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 NPC and show the date of the original request.
If the FO failed to obtain the special Korean application and OIO has mailed it to
If the claim is for Korean disability benefits and either the FO or OIO has provided
the claimant with the Korean Medical Report (KOR-USA 1M).
If attaching material not covered by any block shown above. Briefly explain the attachment
in the space provided for “Remarks.”
If information is being requested from the NPC, check one or more blocks to indicate
the type of material being requested. Check item:
If requesting a Korean coverage record.
If requesting a copy of medical evidence from the NPC's files.
If following up on an earlier request to the NPC and show the date of the original
If requesting information not covered by a block shown above. Briefly explain the
request in the space provided for “Remarks”.
Keep remarks to a minimum and make them clear and concise. Do not use technical jargon
or abbreviations. Be sure to sign and date the form.
Facts about the Korean National Pension Number, GN 01742.315