GN 01744.220 Completing the U.S. - Australian Agreement on Social Security Transmittal/Request/Certification Form (SSA-2960-AUS)
A. When to use
The SSA-2960-AUS is completed in the totalization module in OIO or by VARO in Manila. It is used to:
Transmit claims and related material to Centrelink
Request information from Centrelink, and
Respond to requests from Centrelink.
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. Information about the claim
Complete the items in Part 1 as follows:
a. Item A
Always enter the first and last names of the worker.
b. 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.
c. Item C
Check the appropriate sex of the worker.
d. Item D
Always enter the Australian Customer Reference Number (CRN) if the number is shown on the application or on the Australian liaison form.
e. Item E
Always enter the worker's U.S. SSN.
f. Items F, G, and H
Always enter the complete name, maiden name, and U.S. SSN of the claimant if the claimant is not the worker entered in Item A.
g. Item I
Always enter the complete address and telephone number of the claimant.
h. Item J
On initial claims packages, indicate the type of claim for U.S. benefits and/or Australian benefits in the appropriate columns.
i. Item K
Enter the filing date being certified to Centrelink on all initial claims packages or in response to Centrelink'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 Australian benefits in response to Centrelink's request for specific information. If the requested information is not available, indicate “unknown.” If the requested information is known but is not verified in SSA records, enter the information but do not check the “Verified” block.
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/contributor's date of death
Enter the deceased worker's date of death in survivor claims. Check “Verified” if the date 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 spouse or widow(er) 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 spouse or widow(er) 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. Item E – work ending date
Enter the date the worker stopped working.
f. Item F – country of birth
Enter the country of birth for the worker and the spouse, if applicable. Check “Verified” if the data has been used to award U.S. benefits or the date is shown on the MBR as proven.
g. Item G – citizenship
Enter the country of citizenship of the worker and the spouse, if applicable. Check “Verified” if the data has been used to award U.S. benefits or the date is shown on the MBR as proven.
3. Certification of benefit data
Enter the name of the worker and/or other claimants, type of U.S. benefit being received, the effective date (month of entitlement or October 2002, whichever is later), and the monthly amount. Include all changes in the monthly benefit amount from the effective da