GN 01742.220 Completing the U.S./Korea Agreement on Social Security Transmittal/Request/Certification Form (SSA-2960-KOR)
A. When to use
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.
B. Description of form
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.
1. General information
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.
2. Certification of data
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.
a. Item a – name and date of birth
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.
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.
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 NPC. Check item:
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 the applicant.
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.”
4. Information required
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